Willows Health And Rehab Ctr
1500 E 191st St, Euclid, OH 44117 · For profit - Corporation · 75 certified beds · (216) 486-8880 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- 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 citations for mishandling residents’ money or property (F0567, F0568)
- it has 2 actual-harm citations
- a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $39,683 in federal fines (most recent 2024-05-23)
- its facility-reported quality-measure score sits well above its independent inspection score
- its payroll-based staffing rating is low (2/5)
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
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) | 2 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 3 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 6.7% | 5.3% | 15.4% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 10.0% | 6.2% | 5.4% | worse |
| 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 | 21.1% | 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 | 0.4% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 4.5% | 6.1% | 16.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 4.3% | 25.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.6% | 3.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 8.7% | 21.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 1.4% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.2% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 71.4% | 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.
Therapy staffing: this home’s payroll records show 0.25 therapist hours per resident per day in 2026Q1 — more than 35% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 3% 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
| 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 — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 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 75 beds and averages 67.4 residents a day — about 90% occupied, or roughly 8 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 3.21 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.33 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.90 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 2.91 hrs/resident/day on weekends vs 3.33 on weekdays — 13% thinner on weekends. RN hours go from 0.39 to 0.18 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 47% is about the same as 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
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.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
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.
25 citations, most serious first. The 12 most serious are shown; the remaining 13 are one tap away and print in full.
- Actual harm · Gcited before2024-05-23 · 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
Based on closed medical record review and staff interview, the facility failed to timely identify and implement interventions to prevent significant/severe weight loss. Actual Harm occurred when Resident #173 was assessed to have a severe 24.8 pound/13.3 percent (%) weight loss in 30 days without evidence of timely identification of the resident's decreased oral intake or timely intervention to address the cause of the weight loss. On 01/17/24 Resident #173 complained of tooth pain and was discovered to have a loose front tooth. The resident complained of continued pain with a decrease in oral intake. On 01/18/24 Resident #173 weighed 186.2 pounds and the next weight obtained on 02/13/24 was 161.4 pounds which reflected a 24.8 pound (severe)/13.3 % weight loss in under 30 days. This affected one resident (#173) of four residents reviewed for nutrition. The facility census was 65 residents. Findings include: Review of the closed medical record for Resident #173 revealed an admission date of 05/18/21 and a discharge date of 02/20/24 with diagnoses that included Alzheimer's disease,…
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.
- Actual harm · G2022-05-09 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such 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, interview and record review, the facility failed to ensure Resident #121's pain was managed effectively. Resident #121 sustained actual harm as evidenced by severe pain and depression when physician ordered Fentanyl patches for pain associated with sickle cell anemia was not provided for eighteen days. This affected one of two residents (Residents #121 and #63) reviewed for pain management. The facility census was 71. Findings include: Review of the Resident #121's medical record revealed an admission date of 04/13/22. Admitting diagnoses included unspecified sequela of cerebral infarction, major depressive disorder, congestive heart failure and sickle cell anemia. Review of the admitting physician orders dated 04/14/22 revealed an order for Fentanyl patch 50 microgram (mcg)/hour one patch transdermal every 72 hours for pain. Review of Resident #121's Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #121 was alert and oriented to time, person and place, and required extensive…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-05-23 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, staff interview, and review of the facility policy the facility failed to develop comprehensive care plans for residents who were smokers. This affected four (Residents #2, #17, #64, #65) of twenty-one residents reviewed for care plans. The facility census was 65 residents. Findings include: Review of a document provided by the facility dated 05/01/24 revealed there were 21 residents who were smokers. Residents #2, #17, #64, #65 were listed as smokers. Review of the medical record for Resident #2 revealed an admission date of 11/12/21 with diagnoses including type two diabetes, hypertension, and atrial fibrillation. Review of the care plan for Resident #2 dated 04/04/24 revealed it did not include a care plan for smoking. Review of the medical record for Resident #17 revealed an admission date of 12/07/23 with diagnoses including type two diabetes, hypertension, and bipolar disorder. Review of the care plan for Resident #17 dated 03/14/24 revealed it did not include a care plan for smoking. Review of the medical record for Resident #64 revealed an admission…
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 before2024-05-23 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, staff interview, family interview, and review of the facility policy, the facility failed to ensure resident care plans with updated with changes in code status. This affected one (Resident #50) of 29 residents reviewed for care plans. The facility census was 65 residents. Findings include: Review of the medical record for Resident #50 revealed an admission date of 09/16/21 with diagnoses including chronic obstructive pulmonary disease (COPD), congestive heart failure, vascular dementia without behavioral disturbance, chronic kidney disease, cardiomegaly, and diabetes. Review of May 2024 physician's orders for Resident #50 revealed an order dated 02/04/24 for the resident be a full code (all resuscitative interventions would be performed in the event the resident's heart stopped). There was an order dated 02/20/24 for Resident #50 to be admitted to hospice care for a diagnosis of COPD. The resident remained a full code. Review of the care plan for Resident #50 dated 02/14/24 revealed the resident's code status was do not resuscitate comfort care…
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 · D2024-05-23 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure accurate pre-dialysis communication was provided to the dialysis center, failed to ensure the dialysis provider provided the facility with timely post-dialysis information, and failed to respond to concerns from the dialysis center. This affected one (Resident #36) of one resident reviewed for dialysis. The facility census was 65 residents. Findings include: Review of the medical record for Resident #36 revealed an admission date of 11/03/23 with diagnoses including end stage renal disease, dependence on dialysis, diabetes, peripheral vascular disease, bilateral below the knee amputation, schizoaffective disorder, and noncompliance with renal dialysis. Review of the physician's orders for Resident #36 revealed an order for the resident to receive hemodialysis outside the facility on Mondays, Wednesdays, and Fridays. The facility was to send a bagged meal/snack with Resident #36 to dialysis. A dialysis communication tool was to be completed and sent to dialysis with the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2022-05-09 · 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 — the official record, unedited, may be distressing
Based on observation and interview the facility failed to store frozen foods under sanitary conditions. This had the potential to affect all 68 residents receiving food from the facility. There were three resident who were not receiving food from the facility (#45, #52, and #66). The facility census was 71. Findings include: On 05/02/22 from 9:48 A.M. to 10:06 A.M. a tour of the kitchen was conducted with Certified Dietary Manager (CDM) #284. During the tour one bag of opened, unlabeled, and undated chicken cubes was found in the freezer. The bottom shelf of one storage rack in the freezer was not six inches from the floor. There was hardened spilled liquid, food, and dirt under the rack. There were multiple food containers stored on the bottom shelf. On 05/02/22 at 10:02 A.M. these findings were verified by CDM, #284.
- Potential for harm · F2022-05-09 · tag F0868 — widespreadHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — the official record, unedited, may be distressing
Based on review of the Quality Assessment and Assurance (QAA) sign-in sheets and staff interview the facility failed to hold quarterly meetings. This had the potential to affect all 71 residents living in the facility. Findings include: Review of QAA sign-in sheets from 05/01/2021 to 05/01/22 revealed a QAA meeting was held on 04/01/22 for the first quarter of 2022. There was no documentation of QAA sign-in sheets for the last three quarters in 2021. Interview with the Administrator on 05/06/22 at 2:42 P.M. confirmed the missing QAA sign-in sheets for the last three quarters of 2021. The Administrator stated she was new to the facility and was unable to locate the sign-in sheets. Review of the facility policy titled Quality Assurance and Performance Improvement (QAPI) Plan undated revealed it was the mission of the facility to provide the highest quality of care possible to all those they were privileged to serve.
- Potential for harm · F2022-05-09 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 observation, staff interview, review of the facility's Coronavirus, (COVID-19) policy, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure staff wore appropriate Personal Protective Equipment (PPE) to prevent the possible spread of COVID-19. This had the potential to affect 21 residents (Resident #14, #21, #24, #27, #31, #32, #33, #41, #42, #43, #44, #46, #48, #54, #58, #64, #65, #171, #172, #173, #174) on the 300 hall. The facility also failed to ensure Legionella water testing laboratory results were addressed in a timely manner. This had the potential to affect 71 residents at the facility. And, the facility failed to ensure infection prevention standards were maintained during wound care. This affected one resident (Resident #62) out of three residents reviewed for pressure ulcer. The facility census was 71. Findings include: 1. Review of the medical record for Resident #174 revealed an admittance date of 05/01/22. Diagnoses included…
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 · E2022-05-09 · tag F0568 — patternProperly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview the facility failed to verify financial records, account transactions or quarterly statements were maintained for resident funds. This affected five of five residents (#29, #58, #60, #61, and #65) reviewed for resident funds and had the potential to affect 33 residents (#2, #5, #8, #11, #12, #13, #15, #16, #17, #23, #24, #26, #27, #29, #31, #33, #35, #36, #42, #43, #44, #49, #50, #53, #54, #58, #60, #63, #65, #67, #70) whose funds were managed by the facility. The facility census was 71. Finding include: Review of the Resident Fund Management Service Authorization and Agreement to Handle Resident Funds forms revealed the facility managed the personal funds for Residents #29, #58, #60, #61, and #65. Interview on 05/06/22 at 2:45 P.M. with Business Office Manager (BOM) #294 revealed she had been at the facility for two weeks and did not know how to access the resident's financial records or obtain quarterly statements. The facility was unable to provide resident financial records or access resident statements. They were therefore unable to show if…
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 before2022-05-09 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure participation of the resident and resident's representative in developing the residents comprehensive care plan. This affected six residents (#4, #10, #30, #45, #52, and #70) of seven residents reviewed for care plan participation. The facility census was 71. Findings include: Review of the medical record for Resident #4 revealed an admission date of 09/10/21. Diagnoses included hypertension and hyperlipidemia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had mildly impaired cognition. Review of Resident #4's progress notes and assessments revealed no evidence care conferences had been conducted. Review of the medical record for Resident #10 revealed an admission date of 05/27/21. Diagnoses included hemiplegia and hemiparesis, dependence on oxygen, and diabetes. Review of the quarterly MDS assessment, dated 01/25/22, revealed the resident had intact cognition. Review of Resident #10's progress notes…
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 · E2022-05-09 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and review of facility drug storage policy and manufacturer's instructions the facility failed to ensure medications were stored according to manufacture guidelines. This affected four residents (Resident #29, #50, #69 and #171) of 71 residents who resided at the facility. Findings include: Observation on [DATE] at 10:00 A.M. of the 300-hallway medication cart revealed an unopened box of nasal spray containing oxymetazoline 0.005 percent, an open bottle Senna-s, a stool softener, a medication cup filled with three round blue tablets, two white oblong pills, one round green tablet, one purple and blue capsule and three and half small round white pills with a piece of paper with a name. Interview on [DATE] at 10:05 A.M. with Licensed Practical Nurse (LPN) #274 revealed she was not assigned to the cart and the nurse who was assigned was on break. LPN #274 verified the findings and stated the medication cup containing the unlabeled medications should have been administered 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.
- Potential for harm · D2022-05-09 · 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 — the official record, unedited, may be distressing
Based on record review and interview the facility failed to ensure the Resident Fund Management Service Authorization and Agreement to Handle Resident Funds form were witnessed for residents whose personal funds were being managed by the facility. This affected one Resident (#58) of five residents (#29, #58, #60, #61, and #65) reviewed for personal funds. The facility census was 71. Findings include: Review of the Resident Fund Management Service Authorization and Agreement to Handle Resident Funds form for Resident #58 revealed the facility failed to have a witnessed authorization form on record for personal funds to be managed by the facility. Interview on 05/06/22 at 4:40 P.M. with Corporate Clinical Nurse #292 confirmed the Resident Fund Management Service Authorization and Agreement to Handle Resident Funds form for Resident #58 was not documented as witnessed.
Show the remaining 13 citations
- Potential for harm · D2022-05-09 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were completed following resident discharge. This affected two of two residents reviewed for discharge (Residents #1 and #10) . Facility census was 71. Findings include: 1. Review of the closed medical record for Resident #1 revealed an admission date of 12/08/21 and discharge date of 12/29/21 to the community. Diagnoses included syphilis, delusional disorders, psychoactive substance use, and altered mental status. Review of Resident #1's MDS assessment dated [DATE] revealed the resident had impaired cognition and was expected to discharge to the community. Review of Resident #1's care plan dated 12/14/21 revealed the resident planned to return to the community. Interventions included to involve specialized home care services and provide written instructions upon discharge. Review of the MDS assessment dated [DATE] revealed the assessment was incomplete and had not been submitted. 2. Review of closed medical…
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 · D2022-05-09 · tag F0660 — isolatedPlan the resident's discharge to meet the resident's goals and 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 interview and record review the facility failed to have a discharge planning process in place which addressed each resident's discharge goals and included identifying changes in the resident's condition which warranted revising the discharge plan. This affected three of three residents (#4, #10, and #30) reviewed for discharge planning. The facility census was 71. Findings include: Review of the medical record for Resident #4 revealed an admission date of 09/10/21. Diagnoses included hypertension and hyperlipidemia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had mildly impaired cognition. Review of the discharge care plan for Resident #4, dated 09/17/21, revealed discharge status was undetermined because the County had temporary guardianship of Resident #4 due to inability to care for self. Interventions included: Resident will return to appropriate safe placement once stable, assess resident/families' ability to perform transfers and activities of daily…
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 · D2022-05-09 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents received services to maintain personal and oral hygiene. This affected four (Residents #60, #62, #24, and #44) of 11 residents reviewed for personal hygiene. Facility census was 71. Findings include: 1. Review of medical record revealed Resident #60 was admitted on [DATE]. Diagnoses included neuromuscular dysfunction of bladder, morbid obesity, hypertension, major depressive disorder, and lymphedema. Review of Resident #60's care plan revised on 01/27/22 revealed Resident #60 required extensive assist with one staff to perform personal hygiene. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 required extensive assist with two persons for personal hygiene. Observation on 05/02/22 at 12:59 P.M. revealed Resident #60 lying in bed with a sheet covering her and uncombed greasy hair. Interview with Resident #60 at the time of the observation revealed she received partial bed baths maybe once 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 · D2022-05-09 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure Resident #62 was treated timely for complaints of abdominal pain. This affected one resident (Resident #62) of one resident reviewed for timely treatment. The facility census was 71. Findings include: Review of medical record revealed Resident #62 was admitted on [DATE]. Diagnoses include cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, dysphagia, hemiplegia and semi paresis, hypertension, anemia, type II diabetes, chronic kidney disease, hyperlipidemia, glaucoma, and major depressive disorder with psychotic symptoms. Interview on 05/05/22 at 9:16 A.M. with Resident #62 revealed that his stomach hurt, he said he was in a lot of pain and he requested medication. This surveyor asked State Tested Nurse Aide (STNA) #278 to notify the nurse since the nurse was with another resident. Observation and interview on 05/05/22 at 10:30 A.M. during wound dressing change revealed Resident #62 stated to 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 · D2022-05-09 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
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 splints ordered by the physician were applied for Resident #7 and #62. This affected two residents (Resident #7 and #62) out of three residents (Resident #7, #32, and #62) reviewed for splints. The facility census was 71. Findings include: 1. Review of medical record revealed Resident #62 was admitted on [DATE]. Diagnoses include cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, dysphagia, hemiplegia and semi paresis, hypertension, anemia, type II diabetes, chronic kidney disease, hyperlipidemia, glaucoma, and major depressive disorder with psychotic symptoms. Review of the physician orders for Resident #62 dated 02/27/22 revealed a physician order for a right-hand splint to be applied daily for six to eight hours as tolerated by resident. Apply with morning care and remove as ordered. Assess skin prior to and after application. Complete passive range of motion to fingers and wrist of 10…
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 before2022-05-09 · 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 interview and record review the facility failed to adequately monitor Resident #45's nutritional status and implement actions to prevent ongoing weight loss. This affected one of two residents reviewed (#45 and #66) for weight loss while on enteral feeding. The facility census was 71. Finding include: Review of the medical record for Resident #45 revealed an admission date of 05/18/21. Diagnoses included encounter for attention to gastrostomy, Alzheimer's disease, and acute and chronic respiratory failure. Review of the admission nursing assessment identified Resident #45 was admitted with a weight of 202 pounds. Review of the 01/20/22 Dietary Quarterly assessment dated [DATE] revealed Resident #45 had a 9.6 percent significant weight loss at one month and three months, and a 13.9 percent significant weight loss at six months. Review of weights revealed on 12/09/22 Resident #45 weighed 185.5 pounds. On 02/01/22 Resident #45 weighed 163.3 pound, a 11.97 percent loss in two months. On 03/02/22 Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-05-09 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for 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, record review, and interview the facility failed to provide dental services for one resident (Resident #62) of two residents (Residents #25 and #62) reviewed for dental concerns. The facility census was 71. Findings include: Review of medical record revealed Resident #62 was admitted on [DATE]. Diagnoses include cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, dysphagia, hemiplegia and semi paresis, hypertension, anemia, type II diabetes, chronic kidney disease, hyperlipidemia, glaucoma, and major depressive disorder with psychotic symptoms. Review of Resident #62's care plan with a revision date of 12/10/18 revealed he was at risk for oral/dental issues related to some missing teeth. Review of the facility dental service report for Resident #62 revealed last dental visit was on 10/11/21. Review of a note authored by Registered Dietitian (RD) #290 dated 12/21/21 revealed Resident #62 had altered dentition and reported some mouth pain and requested…
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 · E2019-04-04 · 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, taste test, interview and record review, the facility failed to serve room trays at palatable temperatures. This had the potential to affect the 73 residents who usually ate their meals in their rooms. The facility census was 78. Findings Include: Observation on 04/02/19 at 11:28 A.M. of tray line temperatures taken by assistant dietary manager #401 revealed all food temperature taken were within the safe temperature zone for serving. The hot food was held at 135 degrees or higher and the cold food was held at 41 degrees or lower. On 04/02/19 at 11:58 A.M. a test tray was completed. Food temperatures were taken by corporate registered dietitian (RD) #403 and the food tasted by the surveyor and RD #403. The green beans and carrots were 125 degrees tasted warm enough. The potatoes were 105 degrees and did not taste warm enough. The pot roast was 110 degrees and did not taste hot enough. The flavor of the food items was good. On 04/02/19 at 11:58 A.M. RD #403 verified the test tray temperatures. Review of Resident Council/Food Committee minutes revealed there 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 · Ecited before2019-04-04 · 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 had the potential to affect 77 out of 78 residents who received meals from the facility's kitchen. One resident (Residents #42) received enteral nutrition and did not receive meals from the kitchen. The facility census was 78. Findings include: Observations during the initial tour of the kitchen 04/01/19 at 9:16 A.M. with assistant dietary manager #401 revealed the shelf above the oven/stove was covered with a layer of greasy dust, the oven handles were dirty, and the hood vent nozzles had grease and dust coating them. The dish machine and the hood above it were spattered with food and had a greasy buildup. There was no record of when the ice machine had been cleaned and sanitized. Interview with the Dietary Manager on 04/01/19 at 9:35 A.M. confirmed all observations. Record review revealed a maintenance record of ice machine cleaning, sanitize and repair completed 11/15/18. On 04/04/19 at 3:30 P.M. the administrator verified the ice machine…
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 · E2019-04-04 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview the facility failed to ensure public bathrooms were in safe operating condition. This affected four of five of the bathrooms available to staff and visitors. The facility census was 78. Findings include: During the survey process from 04/01/19 through 04/04/19 three public bathrooms were noted near the 500 unit. Bathroom #A (to the left of the reception desk, and Men and Women's bathrooms to the right of the reception desk. Bathroom #A had a toilet seat that was broken at the hinges causing it to slide off the rim of the toilet bowl when used. This bathroom was deemed out of order on 04/02/19 when the tank of the toilet was found to be cracked. The Men's bathroom could not be utilized due to a lost key. The Women's bathroom had a extremely loose door handle that had to be wiggled and jostled in a attempt to lineup the locking mechanism with the key. The inside of the bathroom had a sink faucet that was missing the base of the unit, exposing the black plastic type jagged inner surface that could not be cleaned. The bathroom near the reception desk…
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 · D2019-04-04 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based upon interview and record review the facility failed to notify the ombudsman's office when Resident #22 and Resident # 88. This affected two of three residents who were reviewed for discharge from the facility to alternate settings. The facility census was 87. Findings include: 1. Review of the medical record for Resident #22 revealed an admission date of 11/01/18. Diagnoses included congestive heart failure, cerebrovascular disease, anxiety, psychosis, hypertension, and obesity. Review of the nurses notes on 12/10/18 revealed the resident had become lethargic and was noted to have abnormal lab values. The doctor was notified and the resident was discharged to the hospital via emergency transport and was admitted with leukocytosis. Interview with the Administrator on 04/04/19 at 2:17 P.M. confirmed that the facility had not had a system in place to assure the Ombudsman's office was notified when residents were discharged to the hospital and confirmed the office had not been notified when Resident #22 was discharged to the hospital. 2. Review of the medical record for Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-04-04 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure care conferences were held. This affected one resident of one resident (Resident #17) reviewed for care conferences. The facility census was 87. Findings Include: Review of the medical record revealed Resident # 17 was admitted to the facility on [DATE] with diagnosis including hemiplegia and hemiparesis following cerebral infarction, convulsions, chronic kidney disease, major depressive disorder, schizophrenia, anxiety disorder, heart failure, diabetes, atherosclerotic heart disease, alcohol dependence and cocaine dependence. The annual minimum data set (MDS) dated [DATE] revealed Resident #17 required extensive assistance of one person for bed mobility, transfers, walking, locomotion off unit, dressing, toileting and personal hygiene. Supervision was needed for locomotion on the unit. The brief interview mental status (BIMS) score of 15 indicated the resident was cognitively intact. A review of the Resident #17's care plans revealed no…
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 · D2019-04-04 · tag F0814 — failed to dispose of garbage properly — isolatedDispose of garbage and refuse properly.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and staff interview the facility failed to ensure its garbage disposal area was maintained in a clean and sanitary condition. This had the potential to affect all residents. The facility census was 78. Findings Include: Observation of the facilities garbage dumpster area with the assistant dietary manager (ADM) #401 on 04/01/19 at 9:16 A.M. revealed the area was noted to have empty cardboard boxes, disposable gloves, empty containers and other various items around the outside dumpster. ADM #401 verified the above observations at the time of discovery.
“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
$39,683 in federal fines across 1 penalty.
- $39,683 — penalty dated 2024-05-23
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 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 2.9 | +1.1 vs chain |
| Health inspection | 3 of 5 | 2.6 | +0.4 vs chain |
| Staffing | 2 of 5 | 2.2 | -0.2 vs chain |
| Quality measures | 5 of 5 | 4.0 | +1.0 vs chain |
The other 125 homes this chain runs (chain average 2.9★, per CMS)
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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| WWBV HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | since 09/30/2019 |
| OHIO PENNSYSLVANIA PROPERTY LLC | Organization | 5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNF | — | since 03/01/2016 |
| NICOLUZAKIS, GREGORY | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; ADP OF THE SNF | — | since 03/01/2019 |
| VOLPE, BENJAMIN | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; ADP OF THE SNF | — | since 03/01/2019 |
| WEISBERG, WILLIAM | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 03/01/2019 |
| SABER GOVERNANCE LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 09/01/2019 |
| SHG MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/01/2019 |
| CEKANSKI, CYNTHIA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/25/2021 |
| THOMAS, URSULA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/28/2024 |
| CITRIN COOPERMAN ADVISORS LLC | Organization | ADP OF THE SNF | — | since 07/01/2006 |
| SHG BOA LLC | Organization | ADP OF THE SNF | — | since 12/11/2025 |
| SHG MT, LLC | Organization | ADP OF THE SNF | — | since 12/11/2025 |
| TCF NATIONAL BANK | Organization | ADP OF THE SNF | — | since 07/19/2019 |
| MEHTA, DHARMESH | Individual | ADP OF THE SNF | — | since 12/01/2023 |
CMS files one row per role, so the 23 rows in the source record cover these 14 parties — each is shown once here with every role it holds. Nothing is omitted.
8 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $765K paid to related parties — landlords or management companies under common ownership — equal to about 11% 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. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OH
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Ohio Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 365670. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-05-23, 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.