Candlewood Healthcare And Rehabilitation
1835 Belmore Ave, East Cleveland, OH 44112 · For profit - Limited Liability company · 116 certified beds · (216) 268-3600 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Oct 2024
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has citations for mishandling residents’ money or property (F0567, F0569)
- it has 1 actual-harm citation
- a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $29,488 in federal fines (most recent 2024-10-01)
- its facility-reported quality-measure score sits well above its independent inspection score
- 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 | 3 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 2 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
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 improved from 2 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.
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 | 5.9% | 5.3% | 15.4% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 4.1% | 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 | 0.0% | 0.4% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 2.5% | 30.1% | 6.5% | better 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 | 0.8% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 3.4% | 6.1% | 16.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 20.3% | 25.5% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.6% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 21.8% | 21.4% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 9.6% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.4% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 78.6% | 75.6% | 79.4% | typical |
‡ 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.
Therapy staffing: this home’s payroll records show 0.14 therapist hours per resident per day in 2026Q1 — more than 11% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 19% 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not 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 discharge | not 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 discharge | not 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 discharge | not 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 identified | not 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 next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not 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 discharge | not reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not 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 SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 116 beds and averages 89.8 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 3.26 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.40 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.01 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 2.95 hrs/resident/day on weekends vs 3.39 on weekdays — 13% thinner on weekends. RN hours go from 0.47 to 0.23 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 37% is about the same as the national median of 45%. 3 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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.
31 citations, most serious first. The 11 most serious are shown; the remaining 20 are one tap away and print in full.
- Actual harm · Gcited before2024-10-01 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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, medical record review, Self-Reported Incident (SRI) review, witness statement review, policy review and interview, the facility failed to ensure Resident #64 and Resident #93 were free from incidents of physical abuse by Resident #50. This affected two residents (Resident #64 and #93) of six residents reviewed for abuse. Actual harm occurred on 09/24/24 when Resident #93 was physically abused/assaulted by Resident #50 resulting in an injury. At the time of the incident, Resident #50 punched, with a closed fist, Resident #93, unprovoked, resulting in Resident #93 experiencing pain rated a seven out of 10 (on a pain scale with 10 being the most severe pain), headache, distress with crying resulting in a transfer to the hospital emergency department where the resident was admitted to a trauma center for further evaluation and treatment and diagnosed with a nondisplaced right occipital bone fracture. As of 10/01/24 Resident #93 had not returned to the facility. Prior to this incident 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.
- Potential for harm · Dcited before2025-07-31 · tag F0569 — isolatedNotify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure Resident #96's resident fund account was dispersed timely following the resident's discharge from the facility. This affected one resident (Resident #96) of five residents reviewed for funds. The facility census was 88. Findings include:Review of Resident #96's medical record revealed the resident was readmitted on [DATE] and discharged on 06/06/25 with diagnoses including unspecified dementia, paranoid schizophrenia and major depressive disorder. Review of resident fund accounts revealed $767.94 (seven hundred sixty-seven dollars and ninety-four cents) was dispersed on 07/29/25 from Resident #96's resident fund account following the resident's discharge from the facility on 06/06/25. Interview on 07/30/25 at 12:18 P.M. with Regional Director of Operations #920 confirmed Resident #96's resident fund account monies were not dispersed within thirty days as required.
- Potential for harm · D2025-07-31 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, interview and observation, the facility failed to ensure staff followed infection control standards to prevent cross contamination during tracheostomy (a tube in the opening of the trachea for breathing) care. This affected one (Resident #76) of one resident reviewed for tracheostomy care. The facility census was 88. Findings include: Review of the medical record for Resident #76 revealed an admission date of 07/31/20 with diagnoses including brain damage, tracheostomy status and chronic respiratory failure. Review of the physician's orders for Resident #76 for July 2025 revealed staff were to change her inner cannula every day and as needed dated 02/28/25 and to change the tracheostomy ties every night shift and as needed dated 06/29/22. An observation was conducted on 07/29/25 at 12:12 P.M. of tracheostomy care to Resident #76 by Registered Nurse (RN) #868 with Assistant Director of Nursing/Licensed Practical Nurse (LPN) #805 present during the observation. RN #868 washed her hands, put on a surgical mask, gown and gloves. Resident #76's tray table was…
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 · D2024-10-01 · tag F0740 — failed to provide behavioral / mental-health care — isolatedEnsure each resident must receive and the facility must provide necessary behavioral health care and 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 observation, medical record review, Self-Reported Incident (SRI) review, and interview, the facility failed to develop a care plan with individualized interventions to support the behavioral health care needs of Resident #50, who had diagnoses of major depressive disorder, schizophrenia, generalized anxiety disorder, schizoaffective disorder, mood disorder, obsessive compulsive disorder and psychosis. This affected one (Resident #50) of six residents reviewed for behavioral health care needs. Findings include: Review of the medical record for Resident #50 revealed an admission date of 09/23/23 with diagnoses of schizophrenia, dementia with psychotic disturbance, schizoaffective disorder, mood disorder, obsessive compulsive disorder, psychosis, alcohol dependence with alcohol-induced persisting dementia, generalized anxiety disorder and bilateral macular degeneration. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #50 was cognitively intact, had…
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 · D2024-06-17 · tag F0609 — failed to report abuse allegations — isolatedTimely 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 observation, medical record review, policy review and interview, the facility failed to ensure a staff-to-resident physical abuse allegation involving Resident #2 was reported to the Administrator. This affected one resident (#2) of five residents reviewed for abuse. The census was 99. Findings include: Review of the medical record for Resident #2 revealed an admission date of 09/08/23 with diagnoses of cerebral infarction, hemiplegia and hemiparesis affecting left non-dominant side, vascular dementia with mood disturbance, diabetes, gastrostomy, chronic heart failure, anxiety disorder, depression, psychosis and suicidal ideations. Review of the general note dated 04/15/24 revealed Resident #2 was alert and oriented times two and pleasant. He was able to make his needs known to staff. He utilized a Hoyer (mechanical lift) for transfers and two-person maximum assistance with all other activities of daily living. He was incontinent of bowel and bladder. He was NPO (nothing by mouth) and was tolerating…
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 before2024-02-08 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews, the facility failed to ensure kitchen employees were wearing beard guards while preparing and serving food, and failed to ensure drinks on resident meal trays were covered while carrying the trays through the hallways for delivery to the residents. This had the potential to affect all 94 residents receiving meals from the kitchen. The facility identified four residents (#2, #32, #65, and #74) as receiving nothing by mouth. The facility census was 98. Findings include: 1. Observation on 02/01/24 from 12:20 P.M. to 12:25 P.M. revealed State Tested Nursing Assistant (STNA) #336 poured lemonade and fruit punch into plastic cups in an area around the nurse's station and then placed the cups of liquid back onto the meal trays in the covered food cart. STNA #336 then closed the door to the covered food cart and pushed it down the hall and placed the cart in the middle of the hall between room [ROOM NUMBER] and 111. STNA #336 then took Resident #95's meal tray out of the covered food…
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 · Ecited before2024-02-08 · tag F0800 — patternProvide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, review of facility food production sheets and diet type report, the facility failed to ensure Resident #18, #28, #38, #63, #85 and #94 received the pureed main entree in the proper portion size, failed to ensure Residents #19, #44, #49, #50, #60, #76, #77, #86 and #89 received the appropriate main entree for their low sodium diets as ordered, and failed to ensure Residents #13, #17, #21, #23, #25, #26, #30, #34, #41, #87, #91, #53, #54, #67, #69, #72, #73 and #79 received fortified foods as ordered. This affected a total of 33 residents of 94 residents receiving meals from the kitchen. The facility identified four residents (#2, #32, #65 and #74) as receiving nothing by mouth. The facility census was 98. Findings include: 1. Review of the facility food production sheet for lunch on 02/06/24 revealed residents on a puree diet were to receive two number eight scoops of pureed chili. Observation of the lunch tray line on 02/06/24 from 12:07 P.M. to 12:41 P.M. revealed residents who were on a puree diet received one number eight scoop of pureed chili…
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 before2023-10-16 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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, review of the facility Self-Reported Incident (SRI) investigation, review of policy, observations and interviews, the facility failed to ensure Resident #7 and Resident #8 were free from physical abuse. This affected two residents (Resident #7 and #8) out of three residents reviewed for abuse. The facility census was 92. Findings include: 1. Review of the medical record for Resident #8 revealed an admission date of 01/25/19 with diagnoses including schizoaffective disorder, drug-induced subacute dyskinesia, chronic obstructive pulmonary disease, insomnia, vascular dementia without behavior disturbance, psychotic disturbance or mood disturbance, schizophrenia, major depressive disorder, muscle weakness and abnormal gait. Review of Resident #8's Minimum Data Set (MDS) 3.0 assessment, dated 09/12/23 , revealed moderate cognitive deficit with a Brief Interview for Mental Status ( BIMS) score of 10 out of 15. Resident #8 had no physical or verbal behavior exhibited toward others, was a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2022-09-27 · tag F0800 — widespreadProvide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
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 serve food at the proper portion size to meet the residents' nutritional needs. This had the potential to affect 80 residents that received meals from the facility kitchen. Two (Resident's #56 and #58) of 82 residents received nothing by mouth. The facility census was 82. Findings include: Observation 09/20/22 at 5:10 P.M. of the dinner tray line revealed diced parsley potatoes were being served with a green #12 scoop which is equivalent to two and two thirds ounces (oz). The spreadsheet for 09/20/22's dinner meal called for four oz. Whole kernel corn was being served with a green #12 scoop which is equivalent to two and two thirds oz. The spreadsheet for 09/20/22's dinner meal called for four oz. Pureed mashed potatoes was being served with a green #12 scoop which is equivalent to two and two thirds oz. The spreadsheet for 09/20/22's dinner meal called for four oz. Cooked vegetables for mechanical soft diets were being served with a blue #16 scoop which is equivalent to two oz. The spreadsheet for 09/20/22'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 · F2022-09-27 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
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 employ dietary staff who could demonstrate competence in how to properly run a low temperature dish machine. This had the potential to affect all residents receiving meals from the kitchen except for two (Resident's #56 and #58) who did not receive food by mouth. The facility census was 82. Findings include: Observation and interview on 09/19/22 at 11:15 A.M. revealed Dietary Manager (DM) #207 tested the low temperature dish machine. The strips she used did not get a reading, so she checked the chemicals which revealed the sanitizer and rinse aide were emptied. Observation on 09/19/22 at 11:18 A.M. DM #207 and Dietary Aide (DA) #210 went to the storeroom to get sanitizer and returned with rinse aide and three gallons of quat sanitizer. DA #210 stated that there was no sodium hypochlorite solution sanitizer. DM #207 walked away from the dish area. Observation and interview on 09/19/22 at 11:20 A.M. revealed DA #210 was pouring quat…
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 before2022-09-27 · tag F0804 — failed to serve food at safe, palatable temperature — widespreadEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation, and interviews the facility did not ensure food was served at palatable temperatures This had the potential to affect 80 residents that received meals from the facility kitchen. Two (Resident's #56 and #58) of 82 residents received nothing by mouth. Finding include: Interviews on 09/19/22 between 11:00 A.M. and 4:31 P.M. with Resident's #7 (second floor), #44 (third floor), and #79 (second floor) during the screening process of the annual survey revealed complaints about food taste and temperatures which lead to a test tray on 09/20/22. Observation on 09/20/22 at 4:31 P.M. with Corporate Food Service Manager (CFM) #208 revealed he calibrated the food thermometer to the best of his knowledge. Observation of the tray line on 09/20/22 at 5:00 P.M. revealed all hot food items on the steam table were over 165 degrees Fahrenheit (F). There was no heat retention system being used in the kitchen to keep the food warm besides the steam table, thermal domes to cover the plates, and enclosed meal delivery carts. The food truck left the kitchen at 6:04 P.M.…
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.
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- Potential for harm · Fcited before2022-09-27 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, record review, and facility policy review the facility failed to ensure proper ware washing and a clean and sanitary kitchen. This had the potential to affect 80 residents that received meals from the facility kitchen. Two (Resident's #56 and #58) of 82 residents received nothing by mouth. Findings include: 1. A tour of the kitchen on 09/19/22 from 11:00 A.M. to 11:25 A.M. revealed the following: • The walk-in freezer had garlic bread, veal patties, and chicken patties not wrapped properly, labeled, or dated. • Bins that had barley, sugar, and rice were not labeled and dated, and the sugar and rice had scoops sitting directly on the food. • The walk-in refrigerator brats were not wrapped properly, labeled, or dated. Interview on 09/19/22 at 11:07 A.M. [NAME] #102 verified the above observations. Review of the facility policy titled, Labeling and Dating, dated 09/08/21, revealed leftovers and opened items shall be clearly labeled with the date the food item was to be discarded.…
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 · Ecited before2022-09-27 · 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
Based on observation, staff interview, and review of facility drug storage policy and manufacturer's instructions the facility failed to ensure tuberculin purified protein derivative (PPD) and sodium bicarbonate were stored according to manufacture guidelines. This had the potential to effect five (Resident's #8, #14, #20, #57 and #286) who were admitted in the last 30 days and three (Resident's #35, #42, and #62) who received sodium bicarbonate. The facility census was 81. Findings include: Observation on 09/21/22 at 2:30 P.M. with Licensed Practical Nurse (LPN) #213 of the second-floor medication room revealed the refrigerator had one opened multi use vial of PPD solution (used to diagnosis tuberculosis) with an expiration date of 09/26/24. There was no labeled date when the bottle was opened. There was a bottle of sodium bicarbonate (an antacid) with an expiration date of September 2020. Interview on 09/21/22 at 2:30 P.M. with LPN #213 revealed once a multi vial of tuberculin solution was opened the nurse was to document the date on the vial. Review of the manufacturer'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 · D2022-09-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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
Based on observation, interview, record review, and facility policy review the facility failed to ensure medications were not left unattended at the resident's bedside. This affected one (Resident #44) of 82 residents observed for environmental safety. The facility census is 82. Findings included: Review of the medical record for Resident #44 revealed an admission date of 11/25/20 with diagnoses including chronic obstructive pulmonary disease (COPD), asthma, and diabetes. Review of the physician's orders for September 2022 revealed an order for ipratropium-albuterol solution, a breathing treatment, 0.5-2.5 milligrams (mg) in 3 milliliters (ml) with instructions to inhale orally three times a day for shortness of breath related to COPD. There was no order to leave medications at the bedside. Observation on 09/21/22 at 8:35 A.M. of medication administration with Registered Nurse (RN) #143 for Resident #44 revealed she prepared the morning medications including the ipratropium-albuterol breathing treatment. RN #143 entered the room and Resident #143 was self-administering her breathing…
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 · D2022-09-27 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
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, interview, record review, and facility policy review the facility failed to ensure a medication error rate of less than 5%. Two errors were observed in 33 opportunities resulting in a 6.06% medication error rate. This affected two (Resident's #58 and #81) of six (Resident's #4, #6, #44, #58, #61 and #81) observed for medication administration. The facility census was 82. Findings include: 1. Review of the medical record for Resident #81 revealed an admission date of [DATE] with diagnoses including hypertension, need for assistance with personal care, tremor, depression, and anxiety. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #81 had impaired cognition and required extensive assistance of one staff with bed mobility, transfers, and personal hygiene. Review of the care plan dated [DATE] revealed Resident #81 had a self-care deficit related to cognition and tremors. Intervention included to crush medication and open capsules. Review 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 · D2022-09-27 · tag F0810 — isolatedProvide special eating equipment and utensils for residents who need them and appropriate assistance.
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, medical record review, staff interviews, and facility policy review the facility failed to ensure residents were provided with adaptive equipment to maintain independence while eating. This affected three (Resident's #11, #39 and #81) of eight residents (Residents #4, #8, #11, #25, #39, #51, #67 and #81) who received adaptive eating equipment. The facility census was 82. Findings include: 1. Review of the medical record for Resident #11 revealed an admission date of 11/07/14 and a readmission date of 12/16/14 with diagnoses including Alzheimer's disease, paranoid schizophrenia, and dementia with behavioral disturbance. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #11 had impaired cognition and required supervision with set-up only for eating. Review of the physician's orders for September 2022 revealed a diet order for mechanical soft texture with no nutritional restrictions with thin consistency liquids. Resident #11 was also ordered a scoop…
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 before2022-09-27 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 observations, record review, staff interview, and facility policy review the facility failed to ensure proper infection control during glucose monitoring. This affected one (Resident #6) of five (Resident's #6, #13, #22, #31 and #45) who received glucose monitoring on the second-floor east unit. The facility census was 82. Findings include: Review of the medical record for Resident #6 revealed an admission date of 09/23/221 with diagnoses including type II diabetes, paranoid schizophrenia, and dementia. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 had impaired cognition and received insulin. Review of the care plan dated 04/14/22 revealed Resident #6 had a self-care deficit related to coma, brain injury, and respiratory failure. Intervention included resident had a tube feed and was to receive nothing by mouth (NPO). Review of the September 2022 physician's order revealed order for NovoLog 100 units per millimeter (ml), an insulin, to be injected…
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 · F2019-09-12 · tag F0809 — failed to serve meals on a reasonable schedule — widespreadEnsure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, the facility failed to ensure meals were delivered in a timely manner in accordance to the posted meal times. This affected 109 out of 112 that ate meals in the facility. Residents #37, #52 and #70 received nothing by mouth. The facility census was 112. Finding include: Observation on 09/09/19 from 12:00 to 1:40 P.M. of the lunch meal revealed lunch was delivered to the first floor at 12:47 P.M., second floor was delivered at 1:13 P.M. and third floor was delivered at 1:36 P.M. Interview on 09/09/19 at 12:47 P.M. with Regional Nurse #117 verified the meal times at 12:45 P.M. by giving this surveyor a copy of the meal times. Meal times were as followed: first floor trays to be delivered at 12:00 P.M., second floor at 12:15 P.M. and third floor at 12:45 P.M. and the second truck to third floor at 1:00 P.M. Administrator verified that trays were delivered on first floor at 12:47 P.M., State Tested Nurse Aide (STNA) #30 and STNA #89 verified that second floor was delivered at 1:13 P.M. Trays for third floor were delivered at 1:36 P.M.,…
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 · F2019-09-12 · tag F0921 — failed to keep a safe, functional, sanitary building — widespreadMake 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 record review and staff interview the facility failed to maintain a clean and sanitary environment. This affected all residents. This affected all 75 resident occupied rooms. The facility census was 112. Findings Include: 1. Observation of Resident #95's room on 09/09/19 at 9:15 A.M. revealed dried fecal matter on the floor and toilet seat. The facilities Administrator verified the dried fecal matter at the time of discovery. 2. Observation of Resident #4 on 09/09/19 at 11:00 A.M. revealed Resident #9 was laying perpendicular in her bed and significant areas of dried blood were noted on the sheet of the bed. Licensed Practical Nurse #100 verified the blood stains at the time of discovery. 3. An environmental tour was conducted on 09/10/19 between 9:22 A.M. and 10:09 A.M. with Maintenance Director #901. The following was observed and verified at the time of discovery. Resident #41 was observed laying in bed on a pillow case that was stained brown. The rooms belonging to Residents #2, #3, #4 #5,#6, #7, #8, #9, #10, #11, #12 #13, #14, #15, #16, #18, #19, #20, #21, #22, #23,…
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 · E2019-09-12 · tag F0558 — failed to accommodate residents' needs and preferences — patternReasonably accommodate the needs and preferences of each resident.
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 staff interview the facility failed to maintain a call light system that was readily accessible to all its residents. This affected 17 (Residents #2, #11, #24, #39,#43, #46 #59, #61,#66 #67, #79 #82, #90, #94, #96, #162, #261) of 112 Residents. The facility census was 11 1. Resident #24 was admitted to the facility on [DATE] with diagnoses including schizophrenia, major depressive disorder and hypertension. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #24 was moderately cognitively impaired and required assistance of one person for activities of daily living. Observation of Resident #24 on 09/09/19 at 10:54 A.M. revealed Resident #24 was laying in bed. Resident #24's call light was observed to be on the floor. Licensed Practical Nurse (LPN) #100 verified Resident #24's call light was not within reach and that Resident #24 is capable of using a call light in an interview on 09/09/19 at 10:55 A.M. 2. An environmental tour was conducted 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 · Ecited before2019-09-12 · 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
Based on observation and staff interview the facility failed to ensure medications were stored in a secured manner. This affected the 44 residents (Residents #4, #14, #15 #17, #20, #21, #25, #26 #28, #29, #30, #37, #38, #39 #42, #44, #47, #49, #52, #55, #60, #62, #64, #69 #70, #71, #72, #73, #75, #77, #78, #81, #83, #86, #88,#91, #92, #95, #97, #102, #104, #105, #311 and #312.) who resided on the first floor and the two south unit. This affected and two of three medication carts observed. The facility census was 112. Findings Include: 1. Observation of the first floor nurse's medication cart on 09/12/19 between 10:44 A.M. and 11:00 A.M. with Registered Nurse (RN) #944 revealed three unidentified loose pills at the bottom of multiple drawers through out the medication cart. RN # 944 verified the findings in an interview on 09/12/19 at 11:00 A.M. 2. Observation of the two unit south nurse's medication cart on 09/12/19 between 11:00 A.M. and 11:08 A.M. with Licensed Practical Nurse (LPN) #945 revealed twelve unidentified loose pills at the bottom of multiple drawers through out 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 · Ecited before2019-09-12 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, the facility failed to serve food at a safe/palatable temperature. This had the potential to affect 109 out of 112 residents who ate meals in the facility's kitchen. Three Residents (#37, #52 and #70) received nothing by mouth. The facility census was 112. Finding Include: Interviews by the survey team were made on 09/09/19 between the hours of 8:45 A.M. and 3:00 P.M., Residents #14, #42, #49, #101 and #106 revealed that the food was not served at a palatable temperature. Interviews during the annual survey's resident council on 09/11/19 at 2:30 P.M., Residents #16, #42, #88, #103 and #107 revealed that the food was not served at a palatable temperature many of the meals. On 09/11/19 at 12:05 P.M. a test tray was requested due to multiple complaints about the temperature of the food. The food truck left the kitchen at 1:02 P.M. and arrived on the unit at 1:04 P.M. Food temperatures on the steam table at 12:38 P.M. revealed that all cold food 40 degrees Fahrenheit (F) according to Consulting Dietary Manager (DM) #261. The test tray…
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 · E2019-09-12 · 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 observation, taste test and recipe review, the facility failed to serve pureed foods at a smooth consistency for safe swallowing. This affected eight out of eight residents (#7, #19, #20, #34, #44, 60, #83, and #85) who were prescribed a pureed diet of 109 residents who consumed meals from the facility's kitchen. Residents #37, #52 and #70 received nothing by mouth. The facility census was 112. Findings include: Observation on 09/11/19 at 12:05 P.M. of the lunch meal revealed that the pureed egg salad and pureed macaroni salad had pieces of pimentos on the surface and did not appear smooth. The pureed egg salad and macaroni salad were tasted. The mixture was not smooth and not of proper consistency. Consulting Dietary Manager (DM) #261 verified the consistency of the pureed egg salad and pureed macaroni salad. The Purred egg salad and macaroni salad was at proper consistency at 12:38 P.M. Review of resident diet list revealed residents (#7, #19, #20, #34, #44, 60, #83, and #85) who were prescribed a pureed diet. This was verified by the Registered Dietitian on 09/11/19 at…
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 · Ecited before2019-09-12 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 was maintained in a clean and sanitary manner. This affected 109 out 112 residents who received meals from the dietary department. Resident #37, #52, and #72 were Nothing by Mouth (NPO) and did not receive meals prepared by dietary staff. The facility census was 112. Findings: A tour of the kitchen was conducted on 09/09/19 with the Maintenance Director (MD) #100 from 8:09 A.M. through 8:30 A.M. because the Dietary Manager (MD) was working on breakfast trays. Observation of the kitchen revealed dietary worker #101 was not wearing a hair net; the floors under the dish machine, kitchen oven steamer, and convection oven was covered with heavy dirt and grease build up. The wall by the dish machine contained a heavy black substance. Inspection of the metal transportation meal carts contained dry food particles on the racks and paper on the bottom of the cart Observation of the storage ben holding cooking flour, contain a scoop inside the storage ben. The walk-in cooler contained four large pieces…
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 · E2019-09-12 · tag F0925 — failed to control pests — patternMake 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview the facility failed to ensure its kitchen were free from pests (flies) by having an affective pest control system. This had the potential to affect 109 of 112 residents in the facility. The facility census was 112. Findings include: Observations during the initial tour of the kitchen on 09/09/19 from 8:09 A.M. through 8:30 A.M. with Maintenance Director (MD) #100 revealed there were 12-15 flies near the open section of the dish machine where dirty trays were sent through for washing and trash cans were kept. During this tour of the kitchen, the Consulting Dietary Manager (CDM) #261 could not be present because he was helping with the breakfast trays. Interview with MD #100 on 09/09/19 at 8:30 A.M. verified the observations above. A follow up visit was made on 09/10/19 at 10:20 A.M. with the CDM #261 at 10:20 A.M. revealed multiple flying pest (flies) near the open section of the dish machine where dirty trays were sent through for washing and trash cans are kept.…
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 · D2019-09-12 · tag F0567 — failed to protect residents' money held by the home — isolatedHonor the resident's right to manage his or her financial affairs.
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 resident and staff interview the facility failed to obtain written authorization from the resident or responsible party prior to managing a residents personal funds. This affected one (Residents #12) of eight resident accounts reviewed This had the potential to affect all residents that have accounts. The facility census was 112. Findings Include: Residents #12 was admitted to the facility on [DATE] with diagnoses that included, schizophrenia, type two diabetes and high blood pressure. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #12 cognitively intact. Review demographic information Resident #12 revealed he was his own responsible party. Review of the business office file for Resident #12 noted monthly deposits of 300$ entitled private sector ck deposited into an account managed by the facility. Further review of the business office file for Resident #12 revealed no evidence Resident #12 signed for authorization for the facility to manage his funds.…
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 before2019-09-12 · tag F0569 — isolatedNotify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
What the surveyor found here — the official record, unedited, 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 resident funds were conveyed timely upon resident discharge from the facility. This affected one (Resident #164) of one residents reviewed for funds conveyance. The facility census was 112. Findings Include: Resident #164 was admitted to the facility on [DATE]. Resident #124 expired at the facility on [DATE]. Review of the business records for Resident #164 revealed two separate checks for $21.75 and $1,000 dollars were dispersed to the funeral home handling Resident #164's arrangements on [DATE]. Business Manager #300 verified that Resident #164's funds were conveyed outside of required timeframes (30 days) in an interview on [DATE] at 1:35 P.M.
- Potential for harm · D2019-09-12 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff interview the facility failed to ensure a level two pre admission screen and resident review (PASRR) assessment was completed timely as required. This affected one (Resident #76) of two residents reviewed for PASRR status. The facility census was 112 Findings Include: Resident #12 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, hypertension and nicotine dependence Review of the pre admission screen determination from the local area agency on aging dated 11/95/18 revealed Resident #12 had a level two mental illness and was approved for a seven day stay at the nursing home and that continued stay at the facility required a level two evaluation from the contracted state agency (The Ohio Department of Mental Health) Review of both the electronic and hard charts revealed no other PASRR documentation in Resident #12's record indicating continued approval for stay at the nursing home or that any follow up level two assessment was…
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 · D2019-09-12 · 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
Based on observation, record review, and interview, the facility failed to assess resident blood glucose levels in a timely manner. This affected one (Resident #91) of 27 residents who receive blood glucose testing (Resident #73, #102, #44, #311, #17, #81, #42, #78, #4, #92, #105, #95, #22, #106, #12, #10, #2, #60, #94, #90, #16, #24, #13, #101, #48, #32, and #91). The total census was 112. Findings include: Observation of a blood glucose assessment procedure by Licensed Practical Nurse (LPN) #301 for Resident #91 on 09/10/19 at 9:14 A.M. revealed Resident #91 had already received their breakfast tray and consumed roughly two-thirds of the food on it. Measurement of Resident #91's blood glucose level revealed it to be within normal limits (a value of 92). Interview with LPN #301 immediately following the observation confirmed the glucose check was done late, and was scheduled to be done daily at 8:00 A.M. Record review of Resident #91 revealed an order for blood sugar monitoring to be done once per day at 8:00 A.M. No evidence could be found specifying it was acceptable to wait…
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 · D2019-09-12 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide 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 observation, interview and record review, the facility failed to ensure that the physician's diet order was followed for Resident #30. This affected one resident (Resident #30) out of four (Residents #10, #30, #52 and #77) reviewed for nutrition. The facility census was 112. Findings include: Review of resident's medical record revealed Resident #30 was admitted on [DATE] with diagnoses including but not limited to paranoid schizophrenia, conversion disorder with seizures or convulsions, alkalosis, and chronic pulmonary disease. Resident # 30's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance with one person for most Activities of Daily Living (ADLs) except eating is supervision with set up only. Further review of Resident #30's medical record revealed that nutritional assessment dated [DATE] revealed he was below his Ideal Body Weight (IBW), had a corn intolerance and resident preferred double entrees with a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-09-12 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure proper infection control when administering medications and blood glucose tests. This affected one (Resident #81) of two (Resident #81 and #311) residents on IV (intravenous) medications, and one (Resident #91) of 27 residents who receive blood glucose testing (Resident #73, #102, #44, #311, #17, #81, #42, #78, #4, #92, #105, #95, #22, #106, #12, #10, #2, #60, #94, #90, #16, #24, #13, #101, #48, #32, and #91). The total census was 112. Findings include: 1. Observation of an IV medication administration for Resident #81 by Registered Nurse (RN) #300 on 09/10/19 at 8:33 A.M. revealed she did not wear protective gloves at any point during the procedure, including using an alcohol swab to cleanse the resident's IV access, administering a normal saline flush, and connecting the tubing for the IV medication to the resident. The surveyor confirmed the above observation in interview with RN #300 on 09/10/19 at 8:42 A.M. RN #300 said she did not have to wear gloves at that time because she did not touch any…
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
$29,488 in federal fines across 1 penalty.
- $29,488 — penalty dated 2024-10-01
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 CERTUS HEALTHCARE — 14 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 | 3 of 5 | 1.8 | +1.2 vs chain |
| Health inspection | 3 of 5 | 1.8 | +1.2 vs chain |
| Staffing | 1 of 5 | 1.9 | -0.9 vs chain |
| Quality measures | 5 of 5 | 4.1 | +0.9 vs chain |
The other 13 homes this chain runs (chain average 1.8★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| AJ R&R HOLDING COMPANY LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | 100% | since 04/01/2018 |
| EXTENDED OHIO LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 10% | since 04/01/2018 |
| DIPASQUA, JASON | Individual | W-2 MANAGING EMPLOYEE; CORPORATE OFFICER | — | since 04/01/2018 |
| FISHMAN, SHMUEL | Individual | W-2 MANAGING EMPLOYEE; CORPORATE OFFICER | — | since 04/01/2018 |
CMS files one row per role, so the 7 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.
2 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.
About 90% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.1M paid to related parties — landlords or management companies under common ownership — equal to about 13% 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
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 365353. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-31, 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.