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Dunbar Health & Rehab Center

320 Albany Street, Dayton, OH 45417 · For profit - Corporation · 68 certified beds · (937) 496-6200 Medicare & Medicaid certified

Call the home — (937) 496-6200 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0609, F0610) — most recent May 2025Resident-funds citation (F0565)
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has a citation for mishandling residents’ money or property (F0565)
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • nursing-staff turnover (62%) 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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 3 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

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1 Elizabeth Pl · (937) 424-1050 · Call to confirm hours
Pharmacy
1 Elizabeth Pl · (937) 424-4599 · Call to confirm hours
Grocery
31 S Main St
Park
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 5 of 5
Long-stay residentspeople who live here 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 fell from 4 to 3 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 rating3★
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 increased4.9%5.3%15.4%typical for the state — see note marked double-dagger below the table
Long-stay residents who lose too much weight12.7%6.2%5.4%worse
Long-stay residents with a catheter left in their bladder0.8%0.2%0.9%worse 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 symptoms0.6%30.1%6.5%better 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 injury4.0%3.2%3.3%worse
Long-stay residents whose ability to walk worsened4.6%6.1%16.1%better than state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication29.7%25.5%18.9%worse
Long-stay residents given the seasonal flu vaccine96.2%94.5%95.3%typical
Long-stay residents with pressure ulcers3.8%3.4%4.7%better
Long-stay residents with worsening bladder/bowel control11.7%21.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table10.2%8.8%17.1%better
Short-stay residents who newly got an antipsychotic medication1.3%1.2%1.4%typical
Short-stay residents given the seasonal flu vaccine39.8%75.6%79.4%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.

55.8% 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 28 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

55.8%U.S. median 51.5%
Got home and stayed home
0.18U.S. median 0.31
Therapy hours / resident / day
0.07hours / resident / day
Physical therapy
0.08hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.18 therapist hours per resident per day in 2026Q1 — more than 17% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 SNF55.8%CMS range 29.5–81.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
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 stay0.0%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 worsened9.5%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 hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.111.02Oct 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

0.81
RN hours/ resident / day
1.33
LPN hours/ resident / day
2.24
Aide hours/ resident / day
4.38
Total nurse hours/ resident / day
0.49
RN hoursweekends
62.1%
Total nursing turnover
58.3%
RN turnover

How full it usually is: this home is certified for 68 beds and averages 58.6 residents a day — about 86% occupied, or roughly 9 beds typically open. It runs fairly full. 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 4.38 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.81 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.24 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 3.68 hrs/resident/day on weekends vs 4.66 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 0.94 to 0.49 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 62% is well above the national median of 45%.

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

8
deficiencies at the latest standard inspection (2025-05-01)
6
at the previous standard inspection (2022-09-01)

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.

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.

26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.

  • Potential for harm · D2025-06-18 · tag F0925 — failed to control pests — isolated
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, staff and resident interviews, observations, review of a facility Self-Reported Incident (SRI), review of a video, and policy review, the facility failed to maintain an environment free from pests. This affected two (#60 and #19) of the three residents reviewed for the environment. The facility census was 58. Findings include: Review of the medical record for Resident #60 revealed an admission date of 05/20/25 and discharged on 05/27/25. Diagnoses included chronic respiratory failure with hypoxia, tracheostomy (trach), nontraumatic intracerebral hemorrhage, and diabetes mellitus. Review of a physician order for Resident #60 dated 05/22/25, revealed the resident was ordered to have trach checks and observations completed four times per day and as needed. Review of the discharge Minimum Data Set (MDS) assessment for Resident #60 dated 05/27/25, revealed Resident #60 was dependent for all activities of daily living (ADLs). Review of the facility SRI, dated 05/29/25, revealed the facility completed staff and resident interviews and observations. 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-05-01 · tag F0803 — failed to meet residents' dietary needs — widespread
    Ensure 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 observation, staff interview, and record review, the facility failed to ensure portion sizes were served as planned. This had the potential to affect 57 of 63 residents in the facility. The facility identified six residents (#167, #54, #62, #48, #49, and #43) who did not receive food from the kitchen. The facility census was 63. Findings include: Review of the dietary spreadsheet for the lunch meal on 04/30/25 revealed the serving size for the rice was 1/2 cup, sliced carrots was 1/2 cup, and ground chicken was 3 ounces. Observation on 04/30/25 at 11:04 A.M. revealed [NAME] #735 making plates for the lunch meal. [NAME] #735 utilized a #12 scoop (1/3 cup) for the sliced carrots, a #20 scoop (1 5/8 ounces) for the ground chicken, and a #16 scoop (1/4 cup) for the rice. Observation on 04/30/25 at 11:12 A.M. revealed the first cart of trays was complete and left the kitchen to be delivered to the unit. Interview on 04/30/25 at 11:12 A.M., [NAME] #735 verified she was using a #12 scoop for the sliced carrots, a #20 scoop for the ground chicken, and a #16 scoop for the rice.…

    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 · F2025-05-01 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure 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, staff interview, and record review, the facility failed to ensure the steam table was maintained in a clean and sanitary manner. This had the potential to affect 57 of 63 residents in the facility. The facility identified six residents (#167, #54, #62, #48, #49, and #43) who did not receive food from the kitchen. The facility census was 63. Findings include: Observation on 04/30/25 at 10:26 A.M. revealed the water wells of the steam table in the kitchen contained a yellowish-brown liquid with debris floating at the top and brown sediment around the bottom and edges of each well. Interview at the same time, [NAME] #735 verified the water wells of the steam table contained a yellowish-brown liquid and there was debris floating at the top of the liquid and brown sediment around the bottom and edges of each well. [NAME] #735 described the liquid as grimey and attributed the color to grease falling into the well when taking pans in and out of the steam table. [NAME] #735 stated she planned on cleaning the steam table wells the following day (05/01/25) and stated 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-05-01 · tag F0565 — failed to support the resident council — pattern
    Honor 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 the review of Resident Council meeting minutes, resident interview, and staff interviews, the facility failed to document and follow up on resident concerns from the resident council meetings. This affected 10 out of 10 members of Resident council who regularly attended the meetings and had the potential to affect all residents residing at the facility. The facility census is 63. Findings include: Review of Resident Council meetings minutes from August 2024 to March 2025 revealed the facility did not follow up on concerns brought forward at the Resident Council meetings. Review of the meeting minutes revealed the resolutions from the last meeting concerns were left blank. The meeting concerns that had not been addressed included more outings, a higher activities budget, loud music in other residents' rooms, a pop up facility store, bed linen changes, call lights, and snacks for residents including fresh fruit. Interview on 04/30/25 at 3:14 P.M. with Resident Council President #12 verified that the previous meeting concerns had not been addressed and stated that they do 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-01 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    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, resident interview, family interview, review of the facility's self-reported incident (SRI), staff interview, and policy review, the facility failed to ensure a thorough investigation was conducted on abuse and misappropriation allegations. This affected three (#38, #117, and #12) of three residents reviewed for abuse and misappropriation. The facility census was 63. Findings include: 1. Review of the medical record of Resident #38 revealed an admission date of 03/17/23. Diagnoses included unspecified intracranial injury with loss of consciousness, quadriplegia, depression, dysphagia, anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition. The resident required setup/clean-up assistance with eating and was dependent on staff for all other activities of daily living. 2. Review of the medical record of Resident #117 revealed an admission date of 04/22/22. The resident discharged to another facility…

    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 · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-01 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, observations, staff interviews and policy review. The facility failed to provide nail care for one (#167) dependent resident of two sampled for activities of daily living. The facility census was 63. Findings include: Review of Resident #167's medical record revealed an admission date of 03/13/25. Diagnoses included respiratory failure with ventilator dependence, diabetes, and anxiety. Resident #167 required nutrition through a gastrostomy tube. The most recent Minimum Date Set (MDS ) dated 03/18/25 revealed the resident was totally dependent on staff for all care. Review of the residents activities of daily living plan of care dated 03/18/25 noted the resident is to get nail care weekly with his bath. During an observation of wound care on 04/30/25 at 9:30 A.M., Resident #167 was observed to have long fingernails that were growing downward into his finger tips. Interview with Licensed Practical Nurse (LPN #48 ) 04/30/25 at 9:35 A.M. verified the residents nails were too long. LPN #48 stated they would be taken care of. Review of the facility policy…

    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 · D2025-05-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    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, hospital record review, staff interview, and policy review, the facility failed to ensure falls were thoroughly and timely investigated. This affected two (#46 and #66) of four residents reviewed for falls. The facility census was 63. Findings include: 1. Review of the medical record of Resident #46 revealed an admission date of 11/01/24. The resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. Diagnoses included chronic diastolic (congestive) heart failure, vascular dementia, left femur fracture, and age-related osteoporosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition. Resident #46 was dependent on staff for transfers and toileting and required substantial/maximal assistance with bed mobility. Review of the Fall Risk Assessments dated 11/01/24 and 02/21/25 revealed Resident #46 was a high fall risk. Review of the care plan dated 04/28/25 revealed Resident #46…

    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 · D2025-05-01 · tag F0761 — failed to label and store drugs safely — isolated
    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 medical record review, observation, staff interview and review of facility policy, the facility failed to ensure residents are observed taking medications and medications were not left with residents. This affected one (#31) of 21 residents observed in the sample. The census was 63. Findings include: 1. Review of Resident #31's medical record revealed an admission date of 02/03/20. Diagnoses listed included encephalopathy, malnutrition, psychotic disorder with hallucinations, major depression, and insomnia. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had moderately impaired cognition. Observation on 05/01/25 at 9:40 A.M. revealed Resident #31 was in bed holding a medication cup that contained three pills. Resident #31's eyes were closed. Resident #31 could not be verbally aroused. During an interview on 05/01/25 at 9:43 A.M. Licensed Practical Nurse (LPN) #220 confirmed he had not observed Resident #31 consume the medications. LPN #220 identified 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-01 · tag F0880 — failed to prevent and control infections — isolated
    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, and review of facility policy, the facility failed to ensure enhanced barrier precautions (EBP) were followed and also failed to ensure staff sanitized hands after providing care to a resident and delivering meal trays. This affected three Residents (#19, #54, and #55) observed during dining. The census was 63. Findings include: Review of Resident #54's medical record revealed an admission date of 09/30/24. Diagnoses listed included traumatic brain injury, anxiety, brain cancer, and obstructive sleep apnea. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #54 was severely cognitively impaired and had a feeding tube. Review of physician orders revealed an order dated 02/24/25 for Isolation/Transmission-Based Precautions: Enhanced Barrier Precautions (EBP). Observation on 04/29/25 at 7:42 A.M. revealed Certified Nurse Aide (CNA) #160 and CNA #760 repositioning Resident #54 in bed. Neither CNA #160 or CNA #760 were wearing…

    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 · D2025-02-20 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    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 review of the medical record, staff interviews, and policy review, the facility failed to adequately monitor weights and implement appropriate interventions in a timely manner. This affected one Resident (#64) of the three resident reviewed for significant weight changes. The facility census was 60. Findings include: Review of the closed medical record for Resident #64 revealed an admission date of 06/06/24 with a discharge date of 01/15/25. Diagnoses included epilepsy, major depressive disorder, anxiety disorder, and cerebral infarction. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #64 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 13. This resident was assessed to require setup with eating, dependent with toileting, substantial assistance with bathing and dressing, and partial assistance with transfers. Review of the care plan dated 01/14/25, revealed Resident #64 had increased nutrition/hydration risk related to…

    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
Show the remaining 16 citations
  • Potential for harm · Dcited before2025-02-20 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide 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 review of the medical record and staff interviews, the facility failed to ensure medications were available and administered per physician orders. This affected one Resident (#65) of the three residents reviewed for medication administration. The facility census was 60. Findings include: Review of the medical record for Resident #65 revealed an admission date of 01/06/25 with a discharge date of 01/20/25. Diagnoses included congestive heart failure (CHF), cerebral infarction, and chronic obstructive pulmonary disease (COPD). Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #65 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12. This resident was assessed to require setup with eating, dependent with toileting and transfers, and substantial assistance with bathing and dressing. Review of the physician order dated 01/13/25, revealed Resident #65 was ordered Anbesol liquid (pain relief) 10 percent (%) to rinse…

    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 · D2024-03-05 · 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 record review, observation, staff interview and review of manufacturer instructions, the facility failed to ensure staff primed an insulin pen prior to insulin administration resulting in a significant medication error. This affected one (#22) of six residents observed for medication administration. Facility census was 58. Findings include: Review of medical record for Resident #22 revealed admission date of 07/26/23. Diagnoses include diabetes mellitus type two, hypertension and peripheral vascular disease. Review of the physician orders for Resident #22 revealed an order to administer seven units of insulin Lispro subcutaneously with meals and a start date of 11/02/23. Observation on 03/05/24 at 12:18 P.M. of Registered Nurse (RN) #101 of medication administration for Resident #22 revealed she retrieved an insulin Lispro (fast acting) pen from the medicine cart, she removed the cap and cleansed the hub of the pen with an alcohol swab, she attached the needle and turned the dial if the pen to 7. The medication was given subcutaneously, along with her oral medication. RN…

    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 · E2023-08-22 · tag F0636 — pattern
    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 record reviews, staff interview, and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) manual, the facility failed to ensure residents comprehensive Minimum Data Set (MDS) assessments were completed timely. This affected four (#10, #16, #110, and #118) out of the four residents reviewed for comprehensive MDS assessments. The facility census was 66. Findings include: 1. Review of the medical record for Resident #10 revealed an admission date of 05/15/23 with medical diagnoses of convulsions cerebral infarction, and psychotic disorder. Review of the medical record for Resident #10 revealed an admission MDS with assessment reference date (ARD) of 05/21/23 revealed the MDS had a completion date of 06/23/23. 2. Review of the medical record for Resident #16 revealed an admission date of 06/17/21 with medical diagnoses of atherosclerosis heart disease (ASHD), visual loss both eyes, and chronic kidney disease (CKD) stage III. Review of the medical record for Resident #16 revealed an annual MDS with ARD of 06/26/23 revealed the MDS had a completion date 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-08-22 · tag F0638 — pattern
    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 record reviews, staff interview, and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) manual, the facility failed to ensure residents quarterly Minimum Data Set (MDS) assessments were completed timely. This affected five (#8, #18, #78, #108, and #124) residents out of the six residents reviewed for quarterly MDS assessments. The facility census was 66. Findings include: 1. Review of the medical record for Resident #8 revealed an admission date of 08/10/22 with medical diagnoses of congestive heart failure (CHF), atrial fibrillation, anxiety, and obesity. Review of the medical record revealed a quarterly MDS assessment with Assessment Reference Date (ARD) of 05/20/23 revealed the MDS had a completion date of 07/09/23. 2. Review of the medical record for Resident #18 revealed an admission date of 09/30/22 with medical diagnoses of end stage renal disease (ESRD), dementia, CHF, and anemia. Review of the medical record for Resident #18 revealed a quarterly MDS assessment with ARD of 07/17/23 revealed the MDS had a completion date of 08/04/23. 3. Review…

    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 · D2023-08-02 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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 closed record review, review of manufacturer's recommendations, staff and representative interview, the facility failed to ensure the battery was changed on an external defibrillator vest as ordered. This affected one (#100) of one resident reviewed for external defibrillator care. The facility census was 61. Findings included: Review of the closed medical record revealed Resident #100 was admitted to the facility on [DATE] and discharged on 07/12/23. Resident #100 diagnoses included hyperlipidemia, peripheral vascular disease, type II diabetes with circulatory complications, chronic systolic (congestive) heart failure, hypothyroidism, end stage renal disease, bariatric surgery status, chronic venous hypertension (idiopathic) with ulcer and inflammation of the left lower extremity, cardiac arrest, generalized anxiety disorder, major depressive disorder, moderate protein-calorie malnutrition, atherosclerotic heart disease of the native coronary artery, gastro-esophageal reflux disease, anemia in chronic…

    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 · D2022-09-01 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    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 and resident interview, and policy review, the facility failed to timely report an alleged misappropriation of resident funds to the Administrator and the state agency. This affected one resident (#26) out of one reviewed for misappropriation. The facility census was 47. Findings include Review of the medical record for the Resident #26 revealed an admission date of 01/11/22. Diagnoses included leg amputation, end stage renal disease, heart failure, anxiety, hypertension. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 was cognitively intact. Resident #26 required extensive assistance of two staff for mobility. Interview on 08/29/22 at 11:22 A.M., with Resident #26 and State Tested Nursing Assistant (STNA) #36 revealed she had a missing $50 bill that had been in a bank envelope on her bed. Resident #26 requested STNA #36 to provide an update on the status of finding the missing money. Resident #26 said the night housekeeper who changed her…

    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 · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-09-01 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    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 Self-Reported Incident (SRI), review of the facility investigation, and policy review, the facility failed to thoroughly investigate an alleged resident to resident abuse. This affected two residents (#18 and #33) out of three residents reviewed for abuse. The facility census was 47. Findings include 1. Review of the medical record for the Resident #18 revealed an admission date of 03/03/22. Diagnoses included congestive heart failure, hypoglycemia, bradycardia, COVID-19, dementia with behaviors, restlessness and agitation and Alzheimer's disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 had cognitive impairment. The resident was independent with mobility requiring supervision and cueing due to cognition. Review of the progress note dated 08/17/22 revealed Resident #18 had a physical altercation on 08/16/22 with another resident where he struck her hand. 2. Review of the medical record for the Resident #33…

    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 · Deficient, Provider has date of correction
  • Potential for harm · D2022-09-01 · tag F0623 — isolated
    Provide 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 medical record review, interview, and policy review, the facility failed to provide a written discharge notice to a resident and resident representative timely. This affected one resident (#38) of one reviewed for discharge. The facility census was 47. Findings include Review of the medical record for the Resident #38 revealed an admission date of 07/29/22 and was hospitalized on [DATE]. Diagnoses included acute respiratory failure, encephalopathy, seizures, tracheostomy, persistent vegetative state and cerebral infarction. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 was not assessed for cognition. Review of the progress note dated 08/08/22 revealed Resident #38 had respirations of 54. The physician was contacted and decision made to transfer out to the hospital. Review of the progress note dated 08/31/22 revealed the social services #92 contacted Resident #38's representative via the telephone and did not want anything sent to her and wants her father to return…

    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 · D2022-09-01 · tag F0625 — isolated
    Notify 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 medical record review, interview, and policy review, the facility failed to ensure a bed hold notice was timely provided to a resident and resident representative upon discharge to the hospital. This affected one resident (#38) of one reviewed for discharge. The facility census was 47. Findings include Review of the medical record for the Resident #38 revealed an admission date of 07/29/22 and was hospitalized on [DATE]. Diagnoses included acute respiratory failure, encephalopathy, seizures, tracheostomy, persistent vegetative state and cerebral infarction. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 was not assessed for cognition. Review of the progress note dated 08/08/22 revealed Resident #38 had respirations of 54. The physician was contacted and decision made to transfer out to the hospital. Review of the progress note dated 08/31/22 revealed the Social Services #92 contacted resident representative by the phone and did not want anything sent to her and wanted…

    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 before2022-09-01 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide 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

    Based on medical record review, interview, and policy review, the facility failed to ensure residents received their medications as ordered. This affected one resident (#33) out of five residents reviewed for unnecessary medications. The facility census was 47. Findings Include: Review of the medical record for Resident #33 revealed admission date of 03/23/21. Diagnoses included acute respiratory failure, protein-calorie malnutrition, iron deficiency anemia cerebellar atoxia disease and anoxic brain damage. Review of the physician orders dated August 2022 revealed Resident #33 was ordered the following medications: Atenolol tablet 100 milligrams (mg) one tablet two times a day for hypertension (HTN). Amlodipine Besylate tablet 10 mg one tablet daily for HTN. Both medications for hypertension had parameters to follow. Gabapentin 300 mg one capsule three times a day for muscle pain. Baclofen tablet 20 mg one tablet four times a day for muscle spasms. Tylenol tablet 325 mg give 650 mg four times a day for pain. Review of the Medication Administration Record (MAR) dated from 08/01/22 to…

    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 · D2022-09-01 · tag F0805 — failed to prepare food in a form residents can eat — isolated
    Ensure 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, interview, review of the pureed recipes, review of the pureed food resource guide, and policy review, the facility failed to ensure pureed foods were made according to a recipe and were the correct consistency. This affected one resident (#05) out of one resident who received a pureed diet. The facility identified no other residents received a pureed diet in the facility. The facility census was 47. Findings include: Review of the medical record for the Resident #05 revealed an admission date of 08/04/09. Diagnoses included kidney failure, schizoaffective disorder, dysphagia, diabetes, dementia, anoxic brain injury, depression, and cognitive communication deficit. Review of the physician order dated 03/07/22 revealed Resident #05 had a diet order for a large portion diet with pureed texture. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #05 had an altered cognition and a mechanically altered diet. Observation and interview on 08/31/22…

    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 · D2019-09-26 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, facility staff interview and Resident Assessment Manual review, the facility failed to timely complete a significant change assessment. This affected one Resident (#27) of one reviewed for timely completion of Minimum Data Set (MDS) assessment. The facility census was 50. Findings include: Medical record review for Resident #27 revealed an admission date on 09/01/18 with diagnoses including high blood pressure, irregular heart rate, blood from the legs to the heart was blocked, skin rash, osteoporosis, stroke, chronic pain syndrome, opioid dependence, falling, weakness, insomnia, major depressive, hepatitis c, malnutrition, acid reflux, and chronic obstructive pulmonary disease (COPD). Review of Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident required extensive assistance for bed mobility, transfers, dressing, toileting and personal hygiene from one staff member. The resident required supervision for eating…

    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 · D2019-09-26 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, and staff interview, the facility failed to implement the use of adaptive devices as care planned for positioning. This affected one Resident (#31) of one resident reviewed for positioning. The facility census was 50. Findings include: Record review for Resident #31 revealed an admission date of 09/16/17 with diagnoses including high blood pressure, obesity, obstructive sleep apnea, depression, heart failure, congestive obstructive pulmonary disease (COPD), anxiety, dysphagia, muscle weakness, hyperlipidemia, malignant tumor, hypothyroidism, anemia, kidney failure, vomiting with blood, constipation, urinary tract infection. Review of Resident #31's occupational therapy (OT) evaluation and treatment record dated 11/29/18 revealed diagnoses included morbid obesity, muscle weakness, and abnormal posture. Long term goals included the resident would achieve and maintain good anatomical alignment while in bed using an arm rest bolster and a cushion as needed for greater…

    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 · D2019-09-26 · 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 record review and staff interview, the facility failed to ensure one (Resident #17) of five sampled residents' blood sugars, were monitored and reported in accordance to physician orders. The facility identified 14 residents with orders for insulin and blood sugar tests out of a facility census of 50 residents. Findings include: Review of Resident #17's medical record, revealed he was admitted to the facility on [DATE], with diagnoses including cerebrovascular disease, ataxia, diabetes, hypertension, cardiac arrhythmia, hyperlipidemia, anxiety disorder, alcohol abuse, transient ischemic attack, cerebral infarction, major depressive disorder with psychotic symptoms, seizures, and insomnia. Review of Resident #17's care plan dated 03/15/18 indicated the resident had diabetes mellitus. Pertinent interventions included to follow facility routines for hypo/hyperglycemic episodes, labs as ordered by doctor, contact doctor with any abnormalities, and administer medication as ordered by the doctor. 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 · D2019-09-26 · tag F0773 — isolated
    Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
    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 resident record review and staff interview; the facility failed to obtain physician ordered laboratory tests. This affected one (#1) of five residents reviewed for unnecessary medication. The census was 50. Findings include: Review of the medical record for Resident #1 revealed the resident was admitted to the facility on [DATE]. Diagnoses include Alzheimer's disease, muscle weakness, psychosis, osteoporosis, anxiety, major depressive disorder, diabetes mellitus type two, hypothyroidism, hyperlipidemia, epilepsy, hypertension, epilepsy, insomnia, and chronic obstructive pulmonary disease. Review of physician orders dated 08/22/17 revealed Resident #1 had physician orders for the laboratory tests fasting blood sugar, lipids, aspartame aminotransferase (AST), and alanine transaminase (ALT) due every six months in June and December, hemoglobin A1c due every three months in March, June, September, and December, phenobarbital level due every six months in August and February, thyroid stimulating hormone…

    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
  • Potential for harm · D2019-09-26 · 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, facility staff interview, and hospice contract review, the facility failed to collaborate in the development of a comprehensive plan of care and maintain the most recent hospice plan of care in the facility. Additionally the facility failed to designate a staff member who was responsible for working with hospice to coordinate care to the resident by both providers. This affected one Resident (#27) of one resident reviewed for hospice services. The facility census was 50. Findings include: Medical record review for Resident #27 revealed an admission date on 09/01/18 with diagnoses including high blood pressure, irregular heart beats, venous insufficiency, skin rash, osteoporosis, hemiplegia affected non dominant side, chronic pain syndrome, opioid dependence, falling, weakness, insomnia, major depressive, hepatitis c, malnutrition, stroke, acid reflux, and chronic obstructive pulmonary disease (breathing disorder). Review of physician's orders for the month of September 2019 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.

    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 SABER HEALTHCARE GROUP — 126 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 3 of 52.9+0.1 vs chain
Health inspection 2 of 52.6-0.6 vs chain
Staffing 3 of 52.2+0.8 vs chain
Quality measures 5 of 54.0+1.0 vs chain
The other 125 homes this chain runs (chain average 2.9★, per CMS)
1 of 5Autumn Care of MarshvilleMarshville, NC 1 of 5Autumn Care of Myrtle GroveWilmington, NC 1 of 5Autumn Care of WaynesvilleWaynesville, NC 1 of 5Brunswick Health & Rehab CenterAsh, NC 1 of 5Bryn Mawr Extended Care CenterBryn Mawr, PA 1 of 5Caring Heights Community Care & Rehab CtrCoraopolis, PA 1 of 5Colonial Health & Rehab Center, LLCVirginia Beach, VA 1 of 5Currituck Health & Rehab CenterBarco, NC 1 of 5Davidson Health & Rehab CenterLexington, NC 1 of 5Edison Manor Nursing & Rehabilitation CenterNew Castle, PA 1 of 5Gastonia Health & Rehab CenterGastonia, NC 1 of 5Greene Health & Rehab CenterGreensburg, PA 1 of 5Grey Stone Health And Rehabilitation CenterFort Wayne, IN 1 of 5Harmar Village Health & Rehab CenterCheswick, PA 1 of 5Highland Pointe Health & Rehab CenterHighland Heights, OH 1 of 5Hilltop Heights Health & Rehab CenterJohnstown, PA 1 of 5Maple Heights Health & Rehab Center, LLCEbensburg, PA 1 of 5Midtown Oaks Health & Rehab CenterAltoona, PA 1 of 5Mountain City Nursing & Rehabilitation CenterHazleton, PA 1 of 5Providence Health & Rehab CenterBeaver Falls, PA 1 of 5River's Bend Health & Rehab CenterHarrisburg, PA 1 of 5Riverside Health & Rehab CenterMcKeesport, PA 1 of 5South Boston Health & Rehab CenterSouth Boston, VA 1 of 5Tallmadge Health & Rehab CenterTallmadge, OH 1 of 5University Manor Health & RehaCleveland, OH 1 of 5Village Care of KingKing, NC 1 of 5Woodhaven Health & Rehab CenterMonroeville, PA 1 of 5Woodlands Health And Rehab CenterRavenna, OH 2 of 5Aurora Manor Special Care CentAurora, OH 2 of 5Autumn Care Of MadisonMadison, VA 2 of 5Autumn Care Of MechanicsvilleMechanicsville, VA 2 of 5Autumn Care Of SuffolkSuffolk, VA 2 of 5Autumn Care of CorneliusCornelius, NC 2 of 5Autumn Care of RaefordRaeford, NC 2 of 5Autumn Care of SaludaSaluda, NC 2 of 5Autumn Care of ShallotteShallotte, NC 2 of 5Azalea Health & Rehab CenterWilmington, NC 2 of 5Bath Manor Special Care CentreAkron, OH 2 of 5Berea Health & Rehab CenterFredericksburg, VA 2 of 5Broad Mountain Health And Rehabilitation CenterFrackville, PA

Showing 40 of 125; 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 / managerTypeRoleSince
ALBANY STREET PROPERTY LLCOrganization5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 09/30/2016
VOLPE, BENJAMINIndividualCORPORATE DIRECTOR; CORPORATE OFFICER; ADP OF THE SNFsince 03/01/2019
WEISBERG, WILLIAMIndividualCORPORATE DIRECTOR; CORPORATE OFFICER; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF; ADP OF THE SNFsince 02/02/2026
NICOLUZAKIS, GREGORYIndividualCORPORATE OFFICER; ADP OF THE SNFsince 03/01/2019
SABER GOVERNANCE LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/01/2019
SHG MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/01/2019
BOWER, THOMASIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/23/2025
SCHAERER, BRITTANYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/06/2023
CITRIN COOPERMAN ADVISORS LLCOrganizationADP OF THE SNFsince 03/01/2015
SABER HEALTHCARE GROUP LLCOrganizationADP OF THE SNFsince 03/01/2015
SHG BOA LLCOrganizationADP OF THE SNFsince 01/16/2026
SHG MT, LLCOrganizationADP OF THE SNFsince 01/16/2026
HUNTER, ROBERTIndividualADP OF THE SNFsince 02/01/2019

CMS files one row per role, so the 24 rows in the source record cover these 13 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.

7 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.

$8.8M
Net patient revenuemost recent cost report
-2.4%
Operating marginrevenue minus expenses
$916K
Related-party expense10% of expenses
Who pays — share of resident-days
Medicaid 35%Medicare 4%Other / private 61%

This home reported $916K paid to related parties — landlords or management companies under common ownership — equal to about 10% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

$428per resident / day
operating cost
$13,007per month
≈ monthly operating cost
$418per 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 366157. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-01, 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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