Beavercreek Post Acute
1974 North Fairfield Road, Dayton, OH 45432 · For profit - Corporation · 110 certified beds · (937) 429-1106 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- it has a citation for mishandling residents’ money or property (F0565)
- it has 1 actual-harm citation
- a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $43,173 in federal fines (most recent 2025-03-20)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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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 | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 6.9% | 5.3% | 15.4% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 3.5% | 6.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.2% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.7% | 0.4% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 96.9% | 30.1% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.2% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 3.9% | 6.1% | 16.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 32.2% | 25.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 91.0% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.5% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 24.9% | 21.4% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 6.9% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.3% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 52.4% | 75.6% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 5.5% | 24.9% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 16.6% | 12.9% | 12.0% | worse |
‡ 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.
61.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 81 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 78.8% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 33 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.39 therapist hours per resident per day in 2026Q1 — more than 68% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 14% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 61.5%CMS range 50.9–71.4 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 8.9%CMS range 6.0–13.8 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 78.8% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 69.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 60.6% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 96.8% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | 94.6% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this 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 discharge | not 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 stay | 3.2% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 4.8% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.6%CMS range 3.5–11.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.10 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 110 beds and averages 84.5 residents a day — about 77% occupied, or roughly 26 beds typically open. It usually has some room. 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 3.05 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.50 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.69 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 2.85 hrs/resident/day on weekends vs 3.13 on weekdays — 9% thinner on weekends. RN hours go from 0.60 to 0.26 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 39% is about the same as the national median of 45%. 1 administrator has left in the past year.
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
Deficiencies are more than at the previous inspection — worsening. 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.
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.
27 citations, most serious first. The 11 most serious are shown; the remaining 16 are one tap away and print in full.
- Actual harm · Gcited before2025-03-20 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
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, resident interview, staff interview, and review of the facility policy, the facility failed to properly and timely assess residents for change in condition. This resulted in Actual Harm for Resident #235 who had constipation with abdominal and rectal pain and had to be treated at the hospital for a fecal impaction. This affected one (Resident #235) of three residents reviewed for change in condition. The facility census was 95 residents. Findings include: Review of the medical record for Resident #235 revealed an admission date of 02/20/25 with diagnoses including wedge compression fracture of T7 and T8 vertebra with routine healing, chronic obstructive pulmonary disease, and fibromyalgia. Review of the Minimum Data Set (MDS) assessment for Resident #235 dated 02/26/25 revealed the resident was cognitively intact and required staff assistance with activities of daily living (ADLs.) Review of the physician's orders for Resident #235 revealed an order dated 02/21/25 for…
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.
- Potential for harm · F2025-03-20 · tag F0803 — failed to meet residents' dietary needs — widespreadEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of menus and spreadsheets, observation, staff interview, medical record review, resident interview, and review of the facility policy, the facility failed to ensure menu portion sizes were followed and menus were reviewed by a dietitian in advance. This affected all of the residents residing in the facility except for one (Resident #61) who received no food by mouth. The facility failed to ensure the resident got to make choices concerning breakfast. This affected three (Residents #22, #45, and #21) of three residents reviewed for choices during the annual survey. The facility census was 95 residents. Findings include: 1. Review of the handwritten menu spreadsheet dated 03/11/25 revealed residents on regular and mechanical soft diets were to receive a number 12 or 2.66 ounce (oz) scoop of scrambled eggs with cheese, one slice of toast, and 6 oz of oatmeal, and residents on pureed diets were to receive a number 12 or 2.66 oz scoop of pureed scrambled eggs with cheese, a number 16 or 2 oz scoop of pureed bread, and a 6 oz scoop of cream of wheat. Observation of the…
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.
- Potential for harm · F2025-03-20 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure the kitchen and food items were maintained in a manner to prevent foodborne illness. This affected all residents in the facility except for one resident (#61) that received no food by mouth. The facility census was 95. Findings include: Observation on 03/10/25 at 8:48 A.M of the kitchen with Dietary Manager (DM) #215 revealed the following kitchen sanitation concerns: there was built up dirt behind the dishwasher, the garbage disposal had rust in the bowl of it, in the dishwasher room there were splashes of a substance running down the walls from the celling to the floor, there were rusty and dusty vents above the steam table area, the window in the kitchen had cobwebs, the wall behind the sink in the kitchen area had splashes of a substance running down the walls, there was an open rusted drain on the floor, the handwashing sink had a white substance running down the entire sink outside and inside, all of the kitchen walls had splashes of a substance on the walls from top to bottom. 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.
- Potential for harm · E2025-03-20 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, observation, staff interview, resident interview, review of staffing schedules, and review of the facility policy, the facility failed to ensure there was adequate staffing to meet residents' needs. This affected one (Residents #61) of two residents reviewed for activities of daily living (ADL) and 10 (Residents #33, #28, #32, #59, #14, #52, #51, #31, #46, #186) of 27 residents sampled. The facility census was 95 residents. Findings include: 1.Review of the medical record for Resident #61 revealed an admission date of 02/10/25 with diagnoses including hip fracture, Alzheimer's disease, and cerebrovascular attack (CVA). Review of the Minimum Data Set (MDS) assessment for Resident #61 dated 02/16/25 revealed the resident was severely cognitively impaired and was dependent on staff assistance with activities of daily living (ADLs.) Observation on 03/11/25 of Resident #61's room revealed the resident's call light was on from 3:38 P.M. to 4:02 P.M. while the resident yelled for the nurse. Further observation revealed Certified Nurse Aide (CNA) #33 entered…
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.
- Potential for harm · E2025-03-20 · tag F0805 — failed to prepare food in a form residents can eat — patternEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of dietary spreadsheets, observation, staff interview and review of facility recipes, the facility failed to ensure pureed eggs and pureed bread were prepared in a form to meet resident needs. This affected four (Residents #33, #42, #57, and #68) of four facility-identified resident who received pureed diets. The facility census was 95 residents. Findings include: Review of the dietary spreadsheet dated 03/11/25 revealed residents on pureed diets pureed scrambled eggs with cheese, pureed bread, and cream of wheat for breakfast. Observation in the kitchen on 03/11/25 at 7:25 A.M. of food to be served to residents on pureed diets revealed the pureed scrambled eggs had dime-sized chunks of eggs in them and the pureed bread had chunks of bread which were approximately one quarter inch in diameter. Interview on 03/11/25 at 8:00 A.M with Dietary Manager (DM) #215 confirmed the pureed scrambled eggs had chunks of egg which had not been blended and there were chunks of bread that were mixed in with the pureed bread. DM #215 confirmed that the pureed eggs and the pureed bread…
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.
- Potential for harm · D2025-03-20 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
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 staff responded to resident requests in a timely manner. This affected one (Resident #61) of two residents reviewed for call lights. Based on medical record review, observation, staff interview and resident interview, the facility failed to ensure the automatic door opener to the front door was functioning properly. This affected one (Resident #43) of 27 residents sampled. The facility census was 95 residents. Findings include: 1.Review of the medical record for Resident #61 revealed an admission date of 02/10/25 with diagnoses including hip fracture, Alzheimer's disease, and cerebrovascular attack (CVA). Review of the Minimum Data Set (MDS) assessment for Resident #61 dated 02/16/25 revealed the resident was severely cognitively impaired and was dependent on staff assistance with activities of daily living (ADLs.) Observation on 03/11/25 of Resident #61's room revealed the resident's call light was on from 3:38 P.M. to 4:02 P.M. while…
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.
- Potential for harm · D2025-03-20 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
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 notify resident physicians of significant weight loss. This affected one (Resident #40) of three residents reviewed for change in condition. The facility census was 95 residents. Findings include: Review of the medical record for Resident #40 revealed an admission date of 05/20/20 with diagnoses including coronary artery disease, heart failure, diabetes, dementia, and aphasia. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #40 dated 11/26/24 revealed the resident was severely cognitively impaired and required set up assistance for eating. Review of the weight records for Resident #40 revealed the resident weighed 133 pounds (lbs.) on 02/06/25 and the resident weighed 123 lbs. on 03/12/25 which was a significant weight loss of 7.5 percent (%) in 33 days. Review of the progress notes for Resident #40 dated 03/12/25 to 03/17/25 revealed the notes did not include documentation of physician or provider notification of the resident's significant weight loss.…
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.
- Potential for harm · D2025-03-20 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
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 activities of daily living (ADL) care was provided for dependent residents. This affected two (Residents #43, #69) of six residents reviewed for ADLs. The facility census was 95 residents. Findings include: 1. Review of the medical record for Resident #43 revealed an admission date of 03/29/23 with diagnoses of hemiplegia and hemiparesis following cerebral infarction, morbid obesity, vascular dementia, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment for Resident #43 dated 01/11/25 revealed the resident was cognitively intact, had limited range of motion to one side of his bilateral upper and lower extremities and was dependent on staff assistance with toileting hygiene and transfers. Review of the care plan for Resident #43 dated 03/06/24 revealed the resident had a self-care deficit related to weakness and impaired mobility due to right sided hemiparesis and hemiplegia following cerebral vascular accident with the…
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.
- Potential for harm · D2025-03-20 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure 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, observation, staff interview, and review of the facility policy, the facility failed to ensure residents did not receive unnecessary medications. This affected one (Resident #43) of five residents reviewed for unnecessary drugs. Findings include: Review of the medical record for Resident #43 revealed an admission date of 03/29/23 with diagnoses including hemiplegia and hemiparesis following cerebral infarction, vascular dementia, and anxiety disorder. Review of the weekly skin assessment for Resident #43 dated 12/11/24 revealed staff identified a fungal wound to the resident's scrotum on 12/04/25. Review of the physician's orders for Resident #43 revealed an order dated 12/14/24 revealed for Mupirocin ointment to the scrotum / tip of penis topically every shift for wound. Review of the wound progress note for Resident #43 dated 12/23/24 revealed there was a wound noted the central anterior scrotum with an order to apply Mupirocin ointment two times daily for seven days and then discontinue. Review of the Minimum Data Set (MDS) assessment for Resident…
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.
- Potential for harm · D2025-03-20 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, observation, staff interview and resident interview, the facility failed to ensure residents were not served food items to which they were allergic. This affected one (Resident #7) of 27 residents sampled. The facility census was 95 residents. Findings include: Review of the medical record for Resident #7 revealed an admission date of 01/27/25 with diagnoses including displaced intertrochanteric fracture of left femur, chronic obstructive pulmonary disease, type two diabetes mellitus, vascular dementia, and congestive heart failure. Review of the Minimum Data Set (MDS) assessment for Resident #7 dated 02/04/25 revealed the resident was moderately cognitively impaired and required set up assistance with eating. Review of the nutritional care plan for Resident #7 dated 02/05/25 revealed the resident was allergic to eggs. Interventions included staff should provide the diet per the physician order. Review of the nutritional assessment for Resident #7 dated 02/05/25 per Registered Dietitian (RD) #501 revealed the resident was ordered a mechanical soft…
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.
- Potential for harm · D2025-01-23 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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 policy review, the facility failed to ensure medications were administered as physician ordered. This affected two (#40 and #102) out of three residents reviewed for medication administration. The facility census was 89. Findings include: 1. Review of the medical record for Resident #40 revealed an admission date of 04/12/18 with diagnoses of hypertensive heart disease without heart failure, paraplegia, and type 2 diabetes mellitus with diabetic autonomic (poly) neuropathy. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 was cognitively intact. Resident #40 was independent with bed mobility, required set-up assistance with eating, oral hygiene, and personal hygiene. Resident #40 required supervision with bathing, dressing, transfers, and wheelchair mobility, and required substantial assistance with toileting hygiene. Review of Resident #40's physician orders revealed an order dated 02/23/24 for Pregabalin Capsule 300 MG,…
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.
Show the remaining 16 citations
- Potential for harm · D2024-12-31 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interviews, the facility failed to provide a safe environment for the residents, staff, and public. This had the potential to affect all residents. The facility census was 86. Findings include: Observation on 12/30/24 at 1:00 P.M. revealed a section of the exterior wall, at the front of the facility with a hole present, without bricks. The area is approximately five-foot width by four foot high. The opening was covered with clean plastic. Upon examination of the interior section that correlated with the exterior wall missing, revealed the opening continued into the interior section of the building with the same opening of approximately five-foot width by four foot high, covered in clean plastic. Interview on 12/30/24 at 1:10 P.M. with Maintenance Director #246 along with the Licensed Nursing Home Administrator (LNHA) confirmed a family member struck the facility, with their vehicle, around Thanksgiving and the facility was waiting on the car owner's insurance to cover the damage. The facility found out the car owner's insurance was not going to cover the…
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.
- Potential for harm · Fcited before2024-08-14 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — the official record, unedited, may be distressing
Based on staff punches, interview, and policy review, the facility failed to ensure a Registered Nurse (RN) was on duty seven days a week for eight consecutive hours. This had the potential to affect all residents. The facility census was 78. Findings include: Review of staff punches for the week of 08/04/24 through 08/10/24 revealed no RN worked on Sunday 08/04/24. Interview on 08/14/24 at 1:53 P.M. with the Administrator verified no RN worked on 08/04/24. Review of policy titled, Staffing and Scheduling, dated 06/08/2022 revealed the facility will comply with Centers for Medicare and Medicaid Services (CMS) and state staffing requirements. This deficiency represents non-compliance investigated under Complaint Number OH00156691.
- Potential for harm · D2024-05-01 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, resident interview, and staff interview, the facility failed to residents were free from significant medication errors. This affected two (Resident #23 and Resident #34) out of three residents reviewed for medications. The facility census was 72. Findings include: Review of the medical record for Resident #23 revealed admission date of 02/16/23 with diagnoses including but not limited to malignant neoplasm of rectum, chronic kidney disease stage two, congestive heart failure, and celiac disease. Review of the Minimum Data Set (MDS) assessment, dated 04/22/24, revealed Resident #23 was cognitively intact. Review of Resident #23's physician orders revealed an order for capecitabine (medication used to treat cancer) 500 milligrams (mg) by mouth, give three tablets one time a day seven days on and seven days off for cancer treatment, and give two tablets by mouth at bedtime seven days on and seven days off for cancer treatment. The order had a start date of 02/24/24. Review of Resident #23's Medication Administration Record (MAR) for March 2024 revealed…
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.
- Potential for harm · Fcited before2024-02-05 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — the official record, unedited, may be distressing
Based on review of staffing schedules and staff interview, the facility failed to use the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 65 residents residing in the facility. Facility census was 65. Findings include: Review of facility staffing schedules and posted staffing information from 12/01/23 through 01/31/24 revealed there was no RN coverage for 01/06/24 and 01/07/24. Interview on 02/01/24 at 1:00 P.M. with the Director of Nursing (DON) verified the facility did not have a RN on duty in the facility on 01/06/24 and 01/07/24 as required. This deficiency represents non-compliance investigated under Complaint Number OH00149862.
- Potential for harm · D2022-08-11 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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 medical record review, review of the facility's policy, and resident and staff interview, the facility failed to conduct quarterly care conference meetings. This affected one (Resident #5) of two residents reviewed for participation in care planning. The facility census was 77. Findings include: Review of the medical record for Resident #5 revealed an admission date of 11/05/20. Diagnosis included congested heart failure (CHF), thrombocytopenia, atrial fibrillation, cerebral vascular accident (CVA), candidiasis of skin and nail, major depressive disorder, chronic obstructive respiratory disease (COPD), and prediabetes. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had intact cognition. The resident required extensive two person assistance for bed mobility, and total two person assistance for transfers. Review of the progress notes revealed the most recent care conference occurred on 10/28/21 at 2:32 P.M. Interview on 08/08/22 at 4:19 P.M. with Resident #5…
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.
- Potential for harm · D2022-08-11 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review and staff interview, the facility failed to have the physician review the pharmacy recommendation to conduct a gradual dose reduction recommendation of psychotropic medications. This affected one (Resident #11) of five residents reviewed for unnecessary medications. The facility census was 77. Findings include: Review of the medical record for Resident #11 revealed an admission date of 11/09/21. Diagnoses included end stage renal disease, schizoaffective disorder, and depression. Review of the monthly medication reviews dated 05/17/22 revealed the pharmacist documented in Resident #11's medical record that an irregularity existed, and a recommendation was made. The pharmacist recommended for the physician to conduct a gradual dose reduction (GDR) for bupropion ER 150 milligrams (depression), lamotrigine 150 milligrams (schizoaffective disorder), and hydroxyzine 50 milligrams (anxiety). Review of Resident #11's medication administration record (MAR) for May 2022, June 2022, and July 2022 revealed no GDR had occurred for bupropion ER 150 milligrams,…
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.
- Potential for harm · D2022-08-11 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
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, review of the facility's policy, and staff interview, the facility failed ensure the residents were offered an influenza vaccine upon admission or yearly during the influenza season. This affected two (Residents #11 and #54) of five residents reviewed for updated influenza vaccines. The facility census was 77. Findings Include: 1. Review of the medical record for Resident #11 revealed an admission date of 11/09/21 with diagnoses including end stage renal disease, schizoaffective disorder, and depression. Further review of the medical record for Resident #11 from November 2021 through August 2022 revealed no documentation that an influenza vaccine had been offered upon admission or after. The medical record also was without documentation that the influenza vaccine had been refused or was contraindicated. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11's influenza vaccine was not administered and the reason for it not given was coded as…
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.
- Potential for harm · E2019-07-25 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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 observation and interview, the facility failed to ensure one of two units of the facility (the 200 unit), received the necessary housekeeping services to maintain a clean, orderly environment. The facility identified 51 Residents (#1, #2, #3, #4, #5, #6, #8, #9, #10, #11, #12, #14, #15, #17, #18, #19, #21, #22, #24, #26, #27, #28, #29, #31, #32, #33, #36, #38, #40, #41, #42, #43, #44, #47, #48, #52, #53, #57, #58, #60, #62, #68, #71, #74, #75, #76, #78, #79, #81, #89 and #92) who resided on the 200 unit. The facility census was 91 residents. Findings include: During an environmental tour of the facility conducted on 07/25/19 at 11:30 A.M., with Director of Maintenance #1, the following observations were made on the 200 unit: In room [ROOM NUMBER], the baseboard behind the toilet was loose and detaching from the wall. The flooring in the room and bathroom was dirty with dirt and loose debris. In room [ROOM NUMBER], there was dirt and loose debris underneath bed 2 and along the baseboards of the room. The…
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.
- Potential for harm · E2019-07-25 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 all medications were properly stored and labeled. This affected one of four medication carts observed. This directly affected five Residents (#2, #20, #29, #59 and #63). The facility census was 91. Findings include: Observation on [DATE] at 9:00 A.M. of the one hundred hall medication cart revealed an undated, opened insulin Lispro kwik pen for Resident #29. Observation also revealed an undated, opened insulin Lispro kwik pen for Resident #63. Observation of the same medication cart revealed an undated, opened Latanoprost ophthalmic 0.005% eye drops for Resident #2. Observation of the same medication cart revealed Resident #59's multi-dose Lantus insulin 100 units/milliliter with an expired, opened date of [DATE]. Observation of the same medication cart revealed an opened, Humalog Kwik pen for Resident #20 with an opened date of [DATE]. Interview on [DATE] at 9:15 A.M. with Unit Manager/Registered Nurse (RN) #90…
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.
- Potential for harm · D2019-07-25 · tag F0565 — failed to support the resident council — isolatedHonor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of Resident Council Minutes and responses, Resident Counsel Meeting, resident and staff interviews and review of facility policy the facility failed to ensure responses were provided to the resident council members for three meetings conducted on 06/26/18, 07/24/18 and 02/26/19. This directly affected three Residents (#28, #40 and #244) who attended the resident council meeting. The census was 91. Findings include: Review of Resident Council Minutes from 06/26/18 through 07/25/19 revealed on 06/26/18 the residents complained the floors and bathrooms were not getting cleaned thoroughly and their clothes were coming back from laundry faded and discolored. Review of the minutes dated 07/24/18 revealed the residents complained about the same wash clothes being used on tables that were used on toilets. Further review of the minutes dated 02/26/19 revealed medications were not given in a timely manner. Review of concern forms from 06/26/18 through 07/25/19 revealed they were silent for 06/26/18, 07/24/18, and 02/26/19 responses. Interviews with Residents Council Member's…
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.
- Potential for harm · D2019-07-25 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal 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 record review, staff interview, and facility policy review, the facility failed to ensure transfer and discharge notices had the required components and failed to ensure residents and/or their representatives were provided the transfer or discharges notice in writing. This affected three (#35, #59, #95) of five residents reviewed. The facility census was 91. Findings include: 1. Medical record review for Resident #95 revealed an original admission date of 06/14/19 and a readmission date of 06/29/19. Diagnosis included pain. Review of the progress notes dated 06/17/19 revealed the resident went out to the hospital for pain to her left lower extremity. Further review of the progress notes dated 06/25/19 revealed the resident was sent out to the hospital for pain to the left lower extremity and indicated transfer/discharge paperwork was sent with the resident. Review of the transfer/discharge form dated 06/25/19 revealed the notice was lacking the proper components as required by the state agency such as:…
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.
- Potential for harm · D2019-07-25 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
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, and staff interview, the facility failed to ensure residents and/or their representatives were given a bed hold notice and the amount of private pay rate was included in the document. This affected three (#35, #59, #95) of five residents reviewed. The facility census was 91. Findings include: 1. Medical record review for Resident #95 revealed an original admission date of 06/14/19 and a readmission date of 06/29/19. Diagnosis included pain. Review of the progress notes dated 06/17/19 revealed the resident went out to the hospital for pain to her left lower extremity. The note was absent for a bed hold notice. Review of the progress notes dated 06/25/19 revealed the resident was sent out to the hospital for pain to the left lower extremity and indicated a bed hold paper was given to the resident. Further review of the medical record revealed there was a bed hold agreement but it was not filled out. Interview with the Director of Nursing (DON) on 07/25/19 at 10:12 A.M. verified the bed hold…
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.
- Potential for harm · D2019-07-25 · tag F0641 — isolatedEnsure 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, observation, and interview, the facility failed to ensure dental assessments were accurate. This affected one (#38) of three residents reviewed for dental services. The facility census was 91 residents. Findings include: Review of Resident #38's admission record, revealed he was admitted to the facility on [DATE] with diagnoses including kidney failure, diabetes, Alzheimer's disease, constipation, diabetes, hypertension, anemia, thrombocytopenia, hypokalemia, urinary retention, and hydronephrosis. Review of the significant change Minimum Data Set (MDS) dated [DATE], revealed the resident had cognitive impairment. He required extensive assistance of staff with bed mobility, transfers, dressing, toilet use, and personal hygiene tasks. He was able to feed himself with limited assistance. The MDS also identified the resident as being edentulous (without teeth). Review of the resident's dental care plan dated 09/27/18, revealed the resident had dental or oral cavity health problem as evidenced…
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.
- Potential for harm · D2019-07-25 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to develop a care plan accurately addressing the residents care needs. This affected two (#29 and #38) of 27 residents sampled for care needs. The facility census was 91 residents. Findings include: 1. Review of Resident #29's admission record, revealed she was admitted to the facility on [DATE] with diagnoses including chest pain, diabetes, generalized anxiety, atherosclerotic heart disease, acute hepatitis C, major depressive disorder, hypokalemia, metabolic encephalopathy, old myocardial infarction, and xerosis with prurigo nodularis (skin disease with hard, itchy lumps that form on the skin, causes excessive itching until bleeding occurs). Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident's short/long term memory was intact and she required extensive assistance of staff with bed mobility, transferring, dressing, toilet use, and personal hygiene tasks. Review of the 07/2019 physician order sheet, revealed…
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.
- Potential for harm · D2019-07-25 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
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, observation, resident and staff interview, review of staff schedule, review of activity schedule and review of facility policy the facility failed to provide activities in accordance to residents care plans and preferences. This affected three (#29, #40, #78) of four residents reviewed for activities. The facility census was 91 residents. Findings include: 1. Review of Resident #78's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included seizures, hypertension, anemia, hypothyroidism, anxiety, spastic quadriplegia, attention deficit hyperactivity disorder, overactive bladder, concussion with loss of consciousness of unspecified duration, depression, deep vein thrombosis in right lower extremities, sleep apnea, anemia, and quadriparesis due to auto accident in 2002. Review of the annual Minimum Data Set (MDS) dated [DATE], indicated the resident's short and long term memory were intact. He had no behaviors documented on the MDS. He required extensive…
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.
- Potential for harm · Dcited before2019-07-25 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
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, observation, and resident and staff interview, the facility failed to turn and reposition a resident as ordered. This affected one Resident (#35) of four reviewed for pressure ulcers. The facility census was 91. Findings include: Review of Resident #35 medical record revealed the resident was admitted on [DATE] with diagnoses including Spina Bifida with Hydrocephalus, obesity, paraplegia and sepsis. Review of the minimum data set (MDS) dated [DATE] revealed the resident was cognitively intact. The resident required extensive two-person assistance for bed mobility, dressing, toilet use and personal hygiene. Review of Resident #35's care plan dated 06/06/19 revealed the resident was at risk for alteration in skin integrity related to history of pressure ulcer, morbid obesity, weakness, and paraplegia. Interventions included to encourage the resident to be repositioned. Review of Resident #35's Wound Center physician discharge orders dated 07/10/19 revealed resident must be turned every two…
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.
“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.
- 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.
Fines & penalties
$43,173 in federal fines across 1 penalty.
- $43,173 — penalty dated 2025-03-20
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to PACS GROUP — 274 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.9 | -0.9 vs chain |
| Health inspection | 2 of 5 | 2.5 | -0.5 vs chain |
| Staffing | 1 of 5 | 2.5 | -1.5 vs chain |
| Quality measures | 5 of 5 | 4.4 | +0.6 vs chain |
The other 273 homes this chain runs (chain average 2.9★, per CMS)
Showing 40 of 273; lowest-rated first.
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 / manager | Type | Role | Since |
|---|---|---|---|
| JERGENSEN, JOSHUA | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 12/01/2024 |
| MITCHELL, JOHN | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 12/01/2024 |
| APT, FREDERICK | Individual | CORPORATE OFFICER | since 12/01/2024 |
| PROVIDENCE GROUP NH, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 12/01/2024 |
| GRIMES, NIKITA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/01/2024 |
| TAGGERT, THOMAS | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/25/2025 |
| 1974 NORTH FAIRFIELD ROAD OH OWNER LLC | Organization | ADP OF THE SNF | since 12/01/2024 |
| PROVIDENCE ADMINISTRATIVE CONSULTING SERVICES INC | Organization | ADP OF THE SNF | since 12/01/2024 |
| PROVIDENCE GROUP INC | Organization | ADP OF THE SNF | since 10/21/2025 |
| SNF OH HOLDCO LLC | Organization | ADP OF THE SNF | since 12/01/2024 |
| WELL INTEGRA MASTER JV LLC | Organization | ADP OF THE SNF | since 12/01/2024 |
| WELL PM HOLDCO JV LLC | Organization | ADP OF THE SNF | since 12/01/2024 |
| WELLTOWER OP, LLC | Organization | ADP OF THE SNF | since 12/01/2024 |
| WELLTOWER, INC | Organization | ADP OF THE SNF | since 12/01/2024 |
| KAHLON, GURJEET | Individual | ADP OF THE SNF | since 12/01/2024 |
CMS files one row per role, so the 19 rows in the source record cover these 15 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
9 organizational owners 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.
This home reported $316K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
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
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
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.
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 365374. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-20, 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.