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Stillwater Skilled Nursing And Rehabilitation

75 Mote Drive, Covington, OH 45318 · For profit - Limited Liability company · 75 certified beds · (937) 473-2075 Medicare & Medicaid certified

Call the home — (937) 473-2075 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0602) — cited Feb 2026
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0602), cited Feb 2026
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (1/5)
  • nursing-staff turnover (66%) runs well above the national median (45%)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2600 Mote Dr · (937) 473-3025 · Call to confirm hours
Pharmacy
761 N Pearl St · (937) 473-2993 · Call to confirm hours
Grocery
399 E Troy Pike · (937) 214-1801 · Call to confirm hours
Park
4112 OH-48 · (937) 335-6273 · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 3 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased8.2%5.3%15.4%worse than state — see note marked double-dagger below the table
Long-stay residents who lose too much weight4.7%6.2%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.2%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.4%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms75.4%30.1%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury5.0%3.2%3.3%worse
Long-stay residents whose ability to walk worsened6.7%6.1%16.1%typical for the state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication46.6%25.5%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%94.5%95.3%typical
Long-stay residents with pressure ulcers0.0%3.4%4.7%check this — see note marked star below the table
Long-stay residents with worsening bladder/bowel control26.6%21.4%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table7.5%8.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine97.1%75.6%79.4%better
Short-stay residents rehospitalized after admission42.0%24.9%22.6%worse
Short-stay residents with an outpatient ER visit19.3%12.9%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.131.731.67worse
Long-stay outpatient ER visits per 1,000 resident days1.741.801.80typical

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

61.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 29 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

61.8%U.S. median 51.5%
Got home and stayed home
10.4%U.S. median 10.7%
Went back to hospital
0.52U.S. median 0.31
Therapy hours / resident / day
0.36hours / resident / day
Physical therapy
0.16hours / resident / day
Occupational therapy

Therapy staffing: this home’s payroll records show 0.52 therapist hours per resident per day in 2026Q1 — more than 83% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 17% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF61.8%CMS range 42.5–74.151.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.4%CMS range 7.0–15.610.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay4.2%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.1%CMS range 2.8–11.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.471.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.49
RN hours/ resident / day
1.19
LPN hours/ resident / day
1.87
Aide hours/ resident / day
3.56
Total nurse hours/ resident / day
0.61
RN hoursweekends
66.1%
Total nursing turnover
77.8%
RN turnover

How full it usually is: this home is certified for 75 beds and averages 52.2 residents a day — about 70% occupied, or roughly 23 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.56 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.49 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.87 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.51 hrs/resident/day on weekends vs 3.58 on weekdays — 2% thinner on weekends. RN hours go from 0.45 to 0.61 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 66% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

6
deficiencies at the latest standard inspection (2026-04-16)
12
at the previous standard inspection (2023-03-24)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.

  • Potential for harm · Ecited before2026-04-16 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and review of the facility policy, the facility failed to properly store the resident medications. This had the potential to affect the seven residents with medications stored in the [NAME] Hall cart. The facility census was 46 residents.Findings include: Observation 04/15/26 at 8:20 A.M. of [NAME] Hall medication cart with Licensed Practical Nurse (LPN) #160 revealed there were six loose pills of different sizes, shapes, and colors at the bottom of the cart drawer under the resident medication cards. Interview on 04/15/26 at 8:20 A.M. with LPN #160 confirmed the medication cart drawer had six loose pills at the bottom of the drawer. LPN #160 stated all medications should stored in their original containers and should be discarded if the medication fell to the bottom of the drawer. Review of the facility policy titled Storage of Medications revised April 2019 revealed all drugs and biologicals should be stored a safe, secure, and orderly manner and should be stored in packing, container, or other dispensing systems in which they were received.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-16 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure a comprehensive person-centered care plan included the resident preferences and refusals of cares/services for laryngectomy tube. This affected one (Resident #8) of two residents reviewed for care plans. The facility census was 46 residents. Findings include: Review of the medical record for Resident #8 revealed an admission date of 01/05/24 with diagnoses including malignant neoplasm of larynx, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and tracheostomy status. Review of the Minimum Data Set (MDS) assessment for Resident #8 dated 01/07/26 revealed the resident was cognitively intact, required staff assistance with activities of daily living (ADLs), and received tracheostomy care. Review of the care plan for Resident #8 dated 06/25/25 which stated the resident had laryngeal tube with a history of cutting edge/lip of the tube, stating it was too long. Interventions included the following: ensure tube…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-16 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure a replacement laryngectomy tube (used to keep neck stoma open and to provide a permanent, total airway separation) was at the resident's bedside or easily accessible for staff use. This affected one (Resident #8) of one facility-identified resident with laryngectomy tube. The facility census was 46 residents.Findings include: Review of the medical record for Resident #8 revealed an admission date of 01/05/24 with diagnoses including malignant neoplasm of larynx, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and tracheostomy status. Review of the Minimum Data Set (MDS) assessment for Resident #8 dated 01/07/26 revealed the resident was cognitively intact, required staff assistance with activities of daily living (ADLs), and received tracheostomy care. Review of the physician's orders for Resident #8 revealed an order dated 11/10/25 to remove the laryngectomy tube from the stoma and cleanse the stoma site…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-16 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure residents did not receive unnecessary medications. This affected one (Resident #22) of five residents reviewed for unnecessary medications. The facility census was 46 residents.Findings include: Review of the medical record for Resident #22 revealed an admission date of 10/24/25 with diagnoses of chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, and malignant neoplasm of bronchus and lung. Review of the physician's orders for Resident #22 revealed an order dated 10/27/25 for Azithromycin 250 milligram (mg) one tablet by mouth on Monday, Wednesday, and Friday for infection. Review of the care plan for Resident #22 dated 11/13/25 revealed the resident had signs and symptoms of respiratory infection/COPD exacerbation and was on long term antibiotic for COPD. The goal was for the resident to be free from signs and symptoms of pneumonia /respiratory infection after completion of antibiotics, administer antibiotics as ordered. Review of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-16 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure a medication error rate of five percent (%) or lower. The medication error rate was 7.4% based on two errors out of 27 medication opportunities. This affected one (Resident #34) of the four residents observed for medication administration. The facility census was 46 residents.Findings include: Review of the medical record for Resident #34 revealed an admission date of 07/26/24 with diagnoses including hypertension, atherosclerotic heart disease, asthma, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment for Resident #34 dated 01/31/26 revealed the resident was cognitively intact and required staff assistance with activities of daily living (ADLs.) Review of the physician's orders for Resident #34 dated April 2026 revealed orders for the following 12 morning medications: Eliquis, Claritin, Norco, Lasix- hold if blood pressure less than 120/80, Wellbutrin, amlodipine besylate-hold for blood pressure less than 120/80, allopurinol,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-16 · tag F0881 — failed to use antibiotics responsibly — isolated
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, staff interview, and review of the facility policy, the facility failed to implement the antibiotic stewardship plan and failed to properly monitor antibiotic use. This affected one (Resident #22) of five residents reviewed for unnecessary medications. The facility census was 46 residents.Findings include: Review of the medical record for Resident #22 revealed an admission date of 10/24/25 with diagnoses of chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, and malignant neoplasm of bronchus and lung. Review of the physician's orders for Resident #22 revealed an order dated 10/27/25 for Azithromycin 250 milligram (mg) one tablet by mouth on Monday, Wednesday, and Friday for infection. Review of the care plan for Resident #22 dated 11/13/25 revealed the resident had signs and symptoms of respiratory infection/COPD exacerbation and was on long term antibiotic for COPD. The goal was for the resident to be free from signs and symptoms of pneumonia /respiratory infection after completion of antibiotics, administer…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-02-23 · tag F0602 — failed to protect residents from theft of their belongings — pattern
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, review of Self-Reported Incident (SRI), review of the incident log, review of police statement, review of staff drug screening results, and policy review, the facility failed to ensure resident's controlled substances were not misappropriated. This affected four (#18, #31, #50 and #78) of five residents reviewed for misappropriation. The facility census was 49. Findings include: Review of the medical record for Resident #18 revealed an admission date of 09/29/23 with diagnoses including chronic obstructive pulmonary disease, type two diabetes, and vascular dementia. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #18 is cognitively intact. Review of the physician orders revealed Resident #18 had an active order for Oxycodone. Review of the medical record for Resident #31 revealed an admission date of 12/26/24 with…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · Ecited before2025-11-26 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, staff interviews and policy review, the facility failed to implement their policy to ensure residents with enhanced barrier precautions (EBP) have clear signage and/or instruction on their doors indicating required personal protective equipment (PPE) and care activities that require PPE. Additionally, the facility failed to ensure staff have awareness of the EBP policy and what PPE to use. This affected nine (#13, #18, #20, #30, #34, #39, #42, #43 and #56) out of nine residents reviewed for EBP. The facility census was 57. Findings include: Medical record review for Resident #34 revealed an admission date of 12/19/24. Medical diagnoses included acute embolism and thrombosis of left femoral vein. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 was cognitively intact. Review of Resident #34's care plan dated 10/06/25 revealed the resident required enhanced barrier precautions due to a complex wound/wound care. Medical record…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-06 · tag F0559 — isolated
    Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, interviews with staff and Resident Representative, and facility policy review, the facility failed to ensure Resident Representative was notified of room change prior to a room change. This affected one resident (#54) out of the three residents reviewed for room change notification. The facility census was 55. Findings include: Review of the medical record for Resident #54 revealed an admission date of 10/19/23 with medical diagnoses of mild neurocognitive disorder due to known physiological condition with behavioral disturbances, degenerative disease of the nervous system, depression, dementia, and cerebral atherosclerosis. Review of the medical record for Resident #54 revealed a quarterly Minimum Data Set (MDS) assessment, dated 04/09/25, which indicated Resident #54 had moderate cognitive impairment and was dependent upon staff for all Activities of Daily Living (ADLs). Review of the medical record for Resident #54 revealed the resident had room moves on 01/01/25, 02/27/25 and on 04/14/25. Review of the medical record for Resident #54 revealed a…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-22 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, medical record review, staff interview and review of policies, the facility failed to ensure medications were administered according to physician's order, resulting in a medication error rate which exceeded 5 percent (%). Thirty-five opportunities were observed with four medications errors, resulting in 11.42% error rate. This affected three (#1, #33, #43) of three residents observed during medications administration. The census was 61. Findings included: 1. Review of the medical chart for Resident #1 revealed an admission date of 09/02/15, with diagnosis included hyperlipidemia. Review of the physician's order dated 06/20/23, for Resident #1, revealed an order for Fish Oil 500 milligrams (mg) tablet to give two tablets, one time a day for supplement. Observation of medication administration with Licensed Practical Nurse (LPN) #151 on 08/22/23 at 7:15 A.M., to Resident #1, revealed LPN #151 gave Fish Oil 1000 mg 2 tablets by mouth. Interview with LPN #151 on 08/22/23 at 8:52 A.M., verified she gave Resident #1 Fish Oil 1000 mg two tablets by mouth. Interview…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 15 citations
  • Potential for harm · D2023-08-22 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure staff primed the insulin Flex Pen prior to dialing up medication dose, thus resulting in significant medication error due to resident not receiving the correct amount of insulin. This affected one (#33) of one resident observed for insulin administration. The census was 61. Findings included: Review of the medical record for Resident #33 revealed an admission date of 08/14/21, with diagnosis included diabetes mellitus. Review of physician orders for Resident #33 revealed an order for Novolog Flex Pen 100 unit per milliliters (ml), to give six units with meals for diabetes mellitus. Observation of insulin injection on 08/22/23 at 7:40 A.M., revealed Licensed Practical Nurse (LPN) #151 took out the Novolog Flex Pen, placed a new needle on and dialed up six units of insulin. She injected Resident #33 in the left abdomen. This surveyor did not observe the nurse prime the Flex Pen prior to dialing up the dosage amount. Interview on 08/22/23 at 7:40 A.M., with LPN #151 verified…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-03-24 · tag F0802 — failed to prepare enough nourishing food — widespread
    Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and staff interview, the facility failed to ensure there was sufficient dietary staff to carry out functions of the nutrition services. This affected four (Residents #46, #23, #19, and #31) and had the potential to affect all residents residing in the facility, as all residents received their meals from the facility's kitchen. The facility's census was 56. Findings include: Interview on 03/13/23 at 9:05 A.M. with Dietary Manager (DM) #24 stated there were two aides and one cook working in the facility's kitchen, which was not enough staff to serve residents in the main dining room and halls. DM #24 verified the dining room was closed due to insufficient kitchen staffing. DM #24 reported she requested additional staff, and the facility did hire one new cook who started training on 03/13/23. Observations on 03/13/23, 03/14/23, 03/15/23, and 03/16/23 during mealtimes revealed the main dining room was closed to residents, and meals were served via hall trays to resident rooms. Interview on 03/13/23 at 10:47 A.M. Resident #46 verified the dining room was closed and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-03-24 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, resident and staff interviews, review of facility water temperature logs and review of invoices, the facility failed to ensure comfortable water temperatures were maintained for residents bathrooms and shower room. This affected three (#31, #45, and #46) of three residents reviewed for the physical environment and had the potential to affect 13 (#2, #6, #9, #11, #14, #23, #31, #32, #38, #45, #46, #118, and #309) residents residing on the West-hall. The current census is 56. Findings include: 1. Record review of Resident #45 revealed the resident was admitted to the facility on [DATE]. Diagnoses include conversion disorder with seizures, bipolar disorder, autism, and adjustment disorder. Review of Resident #45's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed there was no assessment completed for the mental score. Review of Resident #45's assessments dated 03/08/23 revealed a mental score assessment was conducted and Resident #45 was scored at a…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-03-24 · tag F0657 — failed to keep the care plan current — pattern
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff and resident interviews, review of Resident Assessment Instrument Manual (RAI) 3.0, the facility failed to conduct care plan review meetings quarterly and failed to include the resident, members of the facility interdisciplinary team (IDT), or resident representative in the care plan review meetings. This affected four (#26, #31, #41, and #48) of the six residents reviewed for quarterly care plan meetings. Additionally, the facility failed to remove a hospice care plan when the services were discontinued. This affected one (#4) of one residents reviewed for hospice services. The facility census was 56. Findings include: 1. Review of the medical record for Resident #26 revealed an admission date of 11/08/19 with medical diagnoses of schizoaffective disorder, major depression, diabetes mellitus, and psychotic disorders with delusions. Review of the medical record for Resident #26 revealed a quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 01/23/23, which…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-03-24 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and review of facility policy, the facility failed to ensure medications were properly stored. This affected one (Resident #46) with the potential to affect five (Residents #50, #32, #37, #22, and #27) identified by the facility as cognitively impaired and ambulatory. The facility's census was 56. Findings include: Medical record review for Resident #46 revealed an admission date of 12/26/22 with diagnoses including chronic pain, low back pain, bipolar disorder, chronic obstructive pulmonary disease, depression, migraine disorder, chronic insomnia due to mental disorder, chronic constipation, pressure ulcer, hypertension, obesity, osteomyelitis, type two diabetes, and Coronavirus 2019 (COVID-19). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 had intact cognition. Resident #46 required extensive assistance to total assistance for bed mobility, transfers, and toileting. Resident #46 was supervised for meal consumption. Review of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-03-24 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, review of facility policy, and of Centers of Disease Control and Prevention (CDC) guidance, the facility failed to ensure a urinary catheter bag was appropriately secured off the floor. This affected one (Resident #4) of one resident reviewed for urinary catheter bag infection control. The facility failed to follow proper isolation procedures for a resident positive with Coronavirus 2019 (COVID-19). This affected one (Resident #46) of one resident reviewed for COVID-19 isolation procedures. The facility failed to ensure staff utilized appropriate Personal Protective Equipment (PPE) when interacting with residents, while the facility had an outbreak of COVID-19 and the community transmission rate was high. This affected one (Resident #15) observed during a staff interaction. Additionally, the facility failed to administer medications following infection control procedures. This affected one (Resident #48) of one resident observed for infection control…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-24 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview and review of the policy, the facility failed to ensure incontinence care was provided in a dignified manner. This affected one (#4) of one resident reviewed for infection urinary catheter care. The facility census was 56. Findings include Medical record review for Resident #4 revealed an admission on [DATE] with diagnoses include Schizophrenia, history of Coronavirus Disease 2019 (COVID-19), neuromuscular dysfunction bladder, insomnia, urine retention, cognitive communication deficit, type two diabetes mellitus, anxiety, memory deficit following cerebrovascular disease. Review of the annual Minimum Data Set (MDS) dated [DATE] for Resident #4 revealed the resident is rarely or never understood. Resident #4 required extensive assist with two staff members for bed mobility, transfers, and extensive assist from two staff members for toileting. Resident #4 requires extensive assist for eating. Resident #4 was coded as having an indwelling Foley catheter.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-24 · tag F0636 — isolated
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, staff interview and review of the Resident Assessment Instrument (RAI) Manual 3.0, the facility failed to complete a comprehensive Minimum Data Set Assessment (MDS) within the required time frame. This affected two (#58 and #259) of two residents reviewed for comprehensive assessments. The facility census was 56. Findings include: 1. Review of the medical record for Resident #259 revealed an admission date of 02/18/23 with medical diagnoses of Alzheimer's disease, unspecified psychosis, hypertension, chronic obstructive pulmonary disease (COPD), and depression. Review of the medical record for Resident #259 revealed an admission comprehensive MDS, with assessment reference date (ARD) of 02/23/23, which indicated Resident #259 had moderate cognitive impairment and required supervision with bed mobility, transfers, toileting, ambulation and eating. Review of the MDS revealed a completion date of 03/08/23. 2. Review of the medical record for Resident #58 revealed an admission date of 12/30/22 with medical diagnoses of rhabdomyolysis, hyperlipidemia,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-24 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, staff interview and review of the Resident Assessment Instrument (RAI) Manual 3.0, the facility failed to complete a significant change in status assessment (SCSA) Minimum Data Set Assessment (MDS) within the required time frame. This affected one (#52) of two residents reviewed for Hospice services. The facility census was 56. Findings include: Review of the medical record for Resident #52 revealed an admission date of 03/09/22 with medical diagnoses of diverticulitis of intestine, atherosclerotic heart disease (ASHD), major Depression, schizophrenia, unspecified psychosis, and dementia. Review of the medical record for Resident #52 revealed a SCSA MDS with assessment reference date (ARD) 02/28/23 which indicated Resident #52 had severely cognitive impairment and required extensive assistance with bed mobility, transfers, toileting, and was dependent for bathing. The MDS indicated Resident #52 received Hospice services. The completion date for Resident #52's SCSA MDS was dated 03/14/23. Review of the medical record for Resident #52 revealed a…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-24 · tag F0638 — isolated
    Assure that each resident’s assessment is updated at least once every 3 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, staff interview and review of the Resident Assessment Instrument (RAI) Manual 3.0, the facility failed to complete quarterly Minimum Data Set Assessment (MDS) within the required time frame. This affected three (#24, #26, and #52) of three residents reviewed for quarterly assessments. The facility census was 56. Findings include: 1. Review of the medical record for Resident #24 revealed an admission date of 08/11/22 with medical diagnoses of schizoaffective disorder, hypertension, Intellectual disabilities, major Depression, bipolar disorder, and anxiety. Review of the medical record for Resident #24 revealed a quarterly MDS, with ARD 02/23/23, which indicated Resident #24 was cognitively intact and required extensive assistance with bed mobility, transfers, toileting and bathing. Review of the MDS revealed a completion date of 03/09/23. 2. Review of the medical record for Resident #26 revealed an admission date of 11/08/19 with medical diagnoses of schizoaffective disorder, major depression, diabetes mellitus, and psychotic disorders with delusions.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-24 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and review of the Resident Assessment Instrument (RAI) Manual 3.0, the facility failed to accurately code Minimum Data Set (MDS) assessments. This affected two (#4 and #26) out of the six residents reviewed for MDS accuracy. The facility census was 56. Findings include: 1. Review of the medical record for Resident #26 revealed an admission date of 11/08/19 with medical diagnoses of schizoaffective disorder, major depression, diabetes mellitus, and psychotic disorders with delusions. Review of the medical record for Resident #26 revealed a quarterly MDS, with an assessment reference date (ARD) of 01/23/23, which indicated Resident #26 was severely cognitively impaired and required supervision with bed mobility, transfers, ambulation, dressing, and toileting. Review of the MDS revealed Resident #26 received an antibiotic for two days during the review period. Review of the medical record for Resident #26 revealed the January Medication Administration Record (MAR) did not…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-24 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, review of the facility policy and review of the Ohio Department of Medicaid website, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR) was accurately completed. This affected one (#39) of one resident reviewed for PASARR accuracy. The facility censes was 56. Findings include: Medical record review for Resident #39 revealed an admission on [DATE] with diagnoses altered mental status, psychosis, depression, pain in left knee, gastroesophageal reflux disease, anxiety, obesity, spinal stenosis, hypertension, disease of spinal cord, encephalopathy, low back pain, viral hepatitis C, bipolar disorder, hypothyroidism, adult failure to thrive, paranoid personality, delusional disorder, infectious and parasitic disease, and hyperlipidemia. Review of quarterly Minimum Data Set (MDS) assessment for Resident #39 dated 02/08/23 revealed impaired cognition. Resident #39 required limited assist for bed mobility, transfers, and toileting from…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-24 · tag F0685 — isolated
    Assist a resident in gaining access to vision and hearing services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, staff interview and facility policy review, the facility failed to provide care and services to maintain or improve communication. This affected one (#16) of one residents reviewed for communication. The facility census was 56. Findings include: Medical record review for Resident #16 revealed an admission on [DATE] with diagnoses include fracture of left pubis, anxiety, urinary tract infection, repeated falls, diabetes with neuropathy, delusional disorders, osteoarthritis, gastroesophageal reflux disease, low back pain, extended spectrum beta lactamase resistance, and psychotic disorder with delusions. Review of the minimum data set (MDS) assessment dated [DATE] for Resident #16 revealed impaired cognition. Resident #16 was coded with adequate hearing. Resident #16 requires supervision for bed mobility, eating and toileting. Review of the plan of care for Resident #16 dated 05/13/17 and revised on 05/11/22 revealed the resident has difficulty at times understanding…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-10-03 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and facility policy review ,the facility failed to monitor laboratory tests in accordance with physician orders to ensure the adequate use of medications for one resident (#44) of five reviewed for unnecessary medications. The faciltiy census was 60. Findings include: Medical record review revealed Resident #44 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke), epilepsy, diabetes mellitus type II, major depressive disorder severe recurrent with psychotic symptoms, chronic obstructive pulmonary disease, and hypertension. Review of Resident #44's current physician orders revealed the resident was ordered Glucotrol 5 milligrams (mg) twice a day, 15 units of Basaglar insulin twice a day, and Trulicity injection of 0.5 milliliter (0.75 mg) every Tuesday. The resident was also ordered to have laboratory tests every three months which consisted of a complete blood count (CBC-to evaluate overall health), comprehensive metabolic…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-10-03 · tag F0849 — isolated
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and facility policy review, the facility failed to have hospice progress notes available for review. This affected one (#26) of one resident reviewed for hospice services. The facility census was 60. Findings include: Medical record review revealed Resident #23 was admitted to the facility on [DATE] with diagnoses including dementia, dysphagia, atherosclerotic heart disease, psychosis, hypertension, malignant neoplasm of breast (cancer), and Alzheimer's disease. The resident was admitted to Hospice services on 05/17/19 with an end stage diagnosis of Alzheimer's disease. Interview on 10/01/19 at 1:08 P.M. with the Unit Licensed Practical Nurse (LPN) #219 revealed the Hospice nurse visits Resident #23 one to two times per week. There was no evidences of any hospice notes in the resident's medical record. Review of the Hospice binder on the unit revealed a comprehensive assessment and hospice care plan dated 05/19/19 were the only notes for Resident #23. Interview on…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Administration Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to MICHAEL SLYK — 7 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 52.9-0.9 vs chain
Health inspection 3 of 53.0≈ chain avg
Staffing 1 of 51.3-0.3 vs chain
Quality measures 4 of 54.4-0.4 vs chain
The other 6 homes this chain runs (chain average 2.9★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
D'AMICO, DANIELIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; ADP OF THE SNF33%since 03/28/2025
SLYK, MICHAELIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER67%since 09/01/2022
RYDER, GWYNNIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/28/2025
MSTC DEVELOPMENT INCOrganizationADP OF THE SNFsince 12/01/2018
DIXON, KOBYIndividualADP OF THE SNFsince 01/01/2025
SLAUGHTER, BRIANNAIndividualADP OF THE SNFsince 01/01/2024

CMS files one row per role, so the 10 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$7.6M
Net patient revenuemost recent cost report
-4.4%
Operating marginrevenue minus expenses
$390K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 79%Medicare 9%Other / private 11%

About 79% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $390K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$374per resident / day
operating cost
$11,368per month
≈ monthly operating cost
$358per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in OH

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Ohio Medicaid page.

Typical monthly cost in Ohio
$9,186/mo
Nursing home (semi-private)
$10,389/mo
Nursing home (private)
$6,103/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 365483. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-16, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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