Good Shepherd Home
725 Columbus Ave, Fostoria, OH 44830 · Non profit - Corporation · 95 certified beds · (419) 937-1801 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (32% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has 1 actual-harm citation
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
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) | 4 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 |
| Short-stay residentsrehab / post-hospital | 4 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 | 7.7% | 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 | 0.3% | 0.2% | 0.9% | worse 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 | 27.3% | 30.1% | 6.5% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.8% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 8.4% | 6.1% | 16.1% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 41.2% | 25.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.3% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 19.3% | 21.4% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 11.5% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.9% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 88.9% | 75.6% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 18.5% | 24.9% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 6.6% | 12.9% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 0.60 | 1.73 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.01 | 1.80 | 1.80 | better |
‡ 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.
44.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 79 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 58.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 31 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.27 therapist hours per resident per day in 2026Q1 — more than 39% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 12% 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 | 44.3%CMS range 34.7–53.9 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.1%CMS range 6.8–13.9 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 58.1% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 51.6% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 48.4% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 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 | 2.7% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.7% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 5.5%CMS range 2.6–9.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.91 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 95 beds and averages 85.3 residents a day — about 90% occupied, or roughly 10 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.60 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.66 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.32 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.87 hrs/resident/day on weekends vs 4.90 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 0.73 to 0.50 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 32% is below 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.
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.
30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.
- Actual harm · G2022-05-16 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interviews, and review of facility policy, the facility failed to identify potential hazards and resident-specific interventions to reduce and/or eliminate falls and falls with injury. This resulted in actual harm when a resident experience repeated falls, with one resulting in a fracture requiring surgery. This affected one resident (#46) out of four residents reviewed for falls. The census was 89. Finding include: Review of the medical record for Resident #46 revealed the resident was admitted to the facility on [DATE]. Diagnoses included muscle weakness, macular degeneration, dementia, anxiety, heart disease and major depressive disorder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 was severely cognitively impaired. The resident required extensive assistance of two people for bed mobility, toilet use and transfers. The assessment revealed Resident #46 had no history of falls prior to admission. Review of the Care Area…
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 · E2026-05-18 · tag F0679 — failed to provide activities — patternProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, review of the activities calendar, and review of the facility policy, the facility failed to implement the activities calendar as scheduled and provide activities to meet resident needs. This affected 37 (#41, #28, #31, #17, #69, #64, #77, #3, #70, #49, #80, #51, #56, #39, #15, #82, #5, #32, #48, #36, #50, #62, #52, #38, #30, #24, #29, #22, #21, #9, #58, #20, #83, #76, #65, #79, and #2) of 37 residents who resided in the memory care unit. The facility census was 80.Findings include:Review of the activities calendar for the memory care unit revealed every day at 9:30 A.M. there was an activity called, Morning Greetings. Repetitive activities were noted on the same day each week. Further review of the activities calendar revealed there were no activities offered past 2:30 P.M. with the exception on 04/07/26 for music time at 3:15 P.M.Observation on 05/11/26 at 9:30 A.M. of the memory care unit revealed there was no activity completed. Observation on 05/11/26 at 10:15 A.M. revealed Activities Director (AD) #142 painting some of the female…
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 before2024-10-10 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, and policy review, the facility failed to store foods properly in the refrigerator and failed to discard expired food items. This had the potential to affect all 83 residents who the facility identified received food from the kitchen. The facility census was 83. Findings include: 1. Observation of the main kitchen refrigerator on 10/07/24 at 8:10 A.M. revealed there was a container of thickened pudding dated 09/23/24 and a container of thickened juice dated 09/23/24 which were outdated and failed to be discarded. Observation of the walk in refrigerator on 10/07/24 at 8:23 A.M. revealed a box of sliced mushrooms were on a wire shelf and were open to air. The cardboard lid failed to be secured to the box. Interview with Culinary Director #251 on 10/07/24 at 8:25 A.M. verified the thickened pudding and thickened juice were outdated and not discarded and the mushrooms were not stored properly. 2. Observation of the pureed food preparation on 10/08/24 at 10:45 A.M. revealed Chef #282 was preparing pureed beef stroganoff. After placing the stroganoff…
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 · E2024-10-10 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation, staff interview, and policy review, the facility failed to prepare pureed foods per the recipe and follow the dietician recommendations for serving sizes. This had the potential to affect six residents (#2, #37, #38, #46, #47, and #68) who received pureed meals and had to the potential to affect 77 residents who received regular or mechanical soft meals from the kitchen. The facility census was 83. Findings include: 1. Review of the Dining Manager's recipe for pureed vegetables revealed the recipe called for one quart of vegetables with one-fourth cup of melted margarine. Observation on 10/08/24 at 10:48 A.M. revealed Chef #282 was preparing the vegetable for the pureed diets. The chef placed the vegetables in the food processor then began pouring in a butter tasting substance used for grilling, sauteing, and pan frying. Chef #282 failed to measure the vegetables nor the butter substance. He poured at least one cup of butter substance in the food processor. Interview with Culinary Director #251 on 10/08/24 at 10:44 A.M. verified Chef #282 did not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-10-10 · tag F0880 — failed to prevent and control infections — patternProvide 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, medical record review, staff interview, facility policy, and review of the Centers of Disease Control and Prevention (CDC) guidance, the facility failed to ensure staff donned appropriate personal protective equipment (PPE) in COVID-19 positive resident's rooms. This had the potential to affect all nine (#48, #49, #65, #67, #73, #76, #82, #88, and #189) residents in the 200 hall who were not COVID-19 positive. In addition, the facility failed to ensure four (#1, #11, #54, and #79) residents with a wound or indwelling medical device had enhanced barrier precautions in place. The facility identified an additional nine (#17, #30, #45, #48, #52, #53, #55, #68, and #189) residents who required enhanced barrier precautions. Additionally, the facility failed to ensure hand hygiene prior to administering medications to Resident #14. The facility census was 83. Findings include: 1. Review of the medical record revealed Resident #188 was admitted on [DATE]. Diagnoses included COVID-19 (10/03/24).…
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 · D2024-10-10 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and facility policy review, the facility failed to ensure resident centered comprehensive care plans were in place. This affected two residents (#5 and #77) of 21 residents reviewed for resident centered comprehensive care plans. The facility census was 83. Findings include: 1. Review of the medical record for Resident #5 revealed an admission date of 07/25/24. Diagnoses included dementia, anxiety, and lewy body dementia. Review of the admission physician orders dated 07/22/24 for Resident #5 revealed she was admitted with an order for Geodon (antipsychotic) 20 milligrams (mg). Review of the admission Minimum Data Set (MDS) dated [DATE] for Resident #5 revealed she was cognitively impaired and was prescribed routine antipsychotic medications. Review of the current physician orders for 10/2024 for Resident #5 revealed the Geodon was discontinued, and Seroquel (antipsychotic) 25 mg was prescribed. Review of the comprehensive care plan initiated 07/2024 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 before2024-10-10 · 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 record review, resident and staff interview, and review of the facility policy, the facility failed to provide showers timely to residents who were dependent on staff for showers/bathing. This affected one (Resident #8) of three residents reviewed for activities of daily living (ADL). The facility census was 83. Findings include: Review of Resident #8's medical record revealed an admission date of 03/17/23. Diagnosis included severe sepsis without shock, chronic obstructive pulmonary disease, and congestive heart failure. Review of Resident #8's quarterly Minimum Data Set assessment dated [DATE] revealed the resident had a moderate cognitive impairment. Resident #8 required substantial assistance from staff for showers, baths, and personal hygiene. Review of Resident #8's care plan revealed she had an ADL self-care self-care performance deficit related to activity intolerance, impaired gait and balance, limited mobility, musculoskeletal impairment, and neuropathy, Interventions included the 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 before2024-10-10 · 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, resident interview, staff interview, and record review, the facility failed to ensure wound prevention boots were in place as physician ordered and failed to obtain a resident's weekly weight as physician ordered. This affected one (Resident (#11) of one resident reviewed for wounds and 21 residents reviewed for physician orders. The facility census was 83. Findings include: 1. Review of Resident #11's medical record revealed an admission date of 12/01/22. Diagnoses included cerebral vascular accident, diabetes mellitus, pressure induced deep tissue damage of right heel, and non-pressure chronic ulcer of right ankle with fat layer exposed. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11's cognition was intact. Resident #11 had an open lesion on his foot and required dressings to the feet. Review of the care plan revealed Resident #11 had altered skin integrity related to a right ankle vascular wound, right anterior third toe traumatic wound, and 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 before2022-05-16 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, and review of facility policy, the facility failed to ensure foods were stored properly, staff prepared food in a sanitary manner, and failed to ensure the dishmachine reached appropriate temperatures. This had the potential to affect 88 residents in the facility. The facility identified one resident (#32) did not receive oral nutrition. The facility census was 89. Findings include: 1. Observations on 05/09/22 beginning at 8:33 A.M. revealed an open bag of chicken, an open box of hashbrowns, and individual flatbread lying loose on the shelf in the walk-in freezer, and one large can of mandarin oranges and one large can of raspberry filling dented near the seal stored with the in-use canned food items. Interview on 05/09/22 at 8:46 A.M. with the Culinary Director #507 confirmed the chicken, hashbrowns and flatbread were stored inappropriately, and the dented cans should be removed from use. Observation and interview on 05/09/22 at 8:52 A.M. with the Culinary Director #507 revealed two opened, undated bags of hardboiled eggs with cloudy fluid…
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 · E2022-05-16 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interviews, and staff interviews, the facility failed to ensure resident rooms and wheelchairs were kept in a clean and sanitary manner. This affected eight residents (#2, #32, #39, #50, #52, #56, #60, and #87) out of eight residents reviewed for environmental concerns. The facility census was 89. Findings include: 1. Observation on 05/10/22 at 8:20 A.M. revealed Resident #39's room smelled of urine. Resident #39 was not in the room at the time. Interview on 05/10/22 at 8:20 A.M. with Medication Aide #513 confirmed Resident #39's room smelled of urine. Observation of Resident #50's room on 05/10/22 from 11:15 A.M. to 11:21 A.M. revealed an unmade bed, dirty linen on the sink and dirty clothing in a pile on the floor in the left hand corner of the room. There was dark, sticky debris on the floor in four of four corners of the room and on the metal threshold between the room and the hallway and the dark, sticky debris rubbed off when scuffed with the Surveyor's shoe. There was also 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 · Ecited before2022-05-16 · tag F0880 — failed to prevent and control infections — patternProvide 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, staff interview, review of manufacturer's instructions, and review of facility policy, the facility failed to ensure staff properly cleaned and disinfected the blood glucometer per manufacturer's recommendations. This had the potential to affect eight residents (#8, #23, #28, #31, #39, #41, #74 and #75) receiving blood sugar checks in the Meadows Unit. Facility census was 89. Findings include: Observation on 05/10/22 at 7:36 A.M. revealed Licensed Practical Nurse (LPN) #376 administering medications on the Meadows Unit and cleaned the blood glucometer with two alcohol wipes. Interview with LPN #376 at the time of the observation on 05/10/22 at 7:36 A.M. verified blood glucometer's are cleaned with alcohol. Interview with LPN #376 on 05/10/22 at 2:30 P.M. verified LPN #376 used alcohol to clean the blood glucometer before and after the morning blood sugar check for Resident #74, with LPN #376 further stating she should have used a disinfectant wipe. Review of facility policy titled, Glucometer Disinfection, with a review date of 02/21 verified blood glucometer…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 19 citations
- Potential for harm · D2022-05-16 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to serve meals to residents in a dignified manner. This affected two residents (#1 and #21) of four residents reviewed for dining. The facility census was 89. Findings include: 1. Review of the medical record for Resident #1 revealed an admission date of 06/10/20. Diagnoses included type II diabetes mellitus and gout. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had intact cognition and required limited assistance of one person for eating. Review of an order dated 01/05/22 revealed Resident #1 received a no added salt diet with pureed food and thin liquids. Observation on 05/09/22 at 11:40 A.M. revealed Resident #1 and Resident #89 sitting together at a dining table. Resident #89 was served her meal at that time, Resident #1 was not. Observation on 05/09/22 at 12:25 P.M. revealed Resident #1 received her meal 45 minutes after Resident #89 received her meal. Interview on 05/09/22 at 12:25 P.M. the Culinary…
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 · D2022-05-16 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interview, the facility failed to provide a comfortable wheelchair for Resident #30. This affected one resident of four reviewed for accommodation of needs. The facility census was 89. Findings include: Review of Resident #30's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including cellulitis (infection of the skin), type two diabetes, gout, lack of coordination, unsteadiness on feet, and dementia with lewy bodies. Assessment completed on 02/20/22 indicated Resident #30 had severe cognitive impairment. The resident's record additionally revealed they were admitted to hospice care on 02/07/22. Observations throughout the afternoon on 05/09/22 found Resident #30 sitting in a geriatric (geri) chair. They were positioned properly but did not appear comfortable as evidenced by his head and shoulders were approximately one foot above the back of the chair. Resident #30 appeared to be sitting stiffly trying to support his head. His face…
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 · D2022-05-16 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, family interview, and review of facility policy, the facility failed to provide a copy of the baseline care plan to Resident #46 or Resident #46's family. This affected one resident (#46) out of seven residents reviewed for care planning. The facility census was 89. Findings include: Review of the medical record revealed Resident #46 was admitted to the facility on [DATE] with diagnoses including muscle weakness, macular degeneration, dementia, anxiety, heart disease and major depressive disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #46 was severely cognitively impaired. Resident #46 required extensive assistance of two people for bed mobility, toilet use and transfers. Review of the baseline care plan for Resident #46 revealed the baseline care plan was developed on 01/19/22, however was the baseline care plan had not been not signed or dated by Resident #46 or by Resident #46's family. Interview on 05/12/22 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 · D2022-05-16 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of facility policy, the facility failed to review and revise a resident's care plan. This affected one resident (#30) out of seven residents reviewed for care plannning. The census was 89. Findings include: Review of Resident #30's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including cellulitis (infection of the skin), type two diabetes, gout, lack of coordination, unsteadiness on feet, and dementia with lewy bodies. Assessment completed on 02/20/22 indicated Resident #30 had severe cognitive impairment. The resident's record additionally revealed admission to hospice care on 02/07/22. Further review of the medical record revelaed Resident #30 had falls on 05/01/22 and 05/03/22. Review of progress notes revealed both falls happened when the resident attempted to stand up from a geriatric (geri) chair. No major injuries were noted for either fall. Review of the care plan for Resident #30 revealed an update…
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 before2022-05-16 · 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, resident interview, staff interview, and review of facility policy, the facility failed to ensure dependent residents received assistance with shaving and fingernail care. This affected one resident (#83) of four residents reviewed for activities of daily living. The facility census was 89. Findings Include: Review of Resident #83's medical record revealed an admission date of 01/04/21. Diagnoses included history of COVID-19, dementia, and weakness. Review of Resident #83's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of nine indicating Resident #83 was moderately cognitively impaired. Resident #83 required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #83 displayed no behaviors during the review period. Review of Resident #83's care plan revised 04/11/22 revealed supports and interventions for risk for having behaviors of rejection of care and getting up unassisted, risk for mood…
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 before2022-05-16 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to provide wound treatments as ordered. This affected one resident (#67) out of five residents reviewed for wound care. The facility census was 89. Findings include: Review of the medical record for Resident #67 revealed an admission date of 11/09/09 with medical diagnoses of abnormal posture and anxiety disorder, and non-pressure chronic ulcer of right ankle with unspecified severity. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #67 had intact cognition and required extensive assistance of two people for bed mobility, dressing, toilet use, personal hygiene, and required total dependence of two people for transfers. Resident #67 used a wheelchair for mobility. Review of Resident #67's orders revealed daily treatment orders for his right outer ankle wound from 12/12/21 through 05/11/22. Review of Resident #67's Treatment Administration Record (TAR) for February 2022 revealed four treatments for his right outer…
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 · D2022-05-16 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, and staff interview the facility failed to ensure residents received timely care and treatment for vision and audiology. This affected one resident (#83) out of one resident reviewed for ancillary services. The facility census was 89. Findings Include: Review of Resident #83's medical record revealed an admission date of 01/04/21. Diagnoses included personal history of COVID-19, dementia and weakness. Review of Resident #83's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of nine indicating Resident #83 was moderately cognitively impaired. Resident #83 had adequate vision and hearing at the time of the review. Review of Resident #83's care plan revised 04/11/22 revealed supports and interventions for risk for having behaviors of rejection of care, preferences for personal care, and self-care deficit. Review of Resident #83's ancillary services consent form revealed on 07/08/21 Resident #83's representative…
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 · D2022-05-16 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, and staff interview, the facility failed to implement ordered treatments to potentially prevent pressure ulcers. This affected one resident (#30) of four residents reviewed for pressure ulcers. The census was 89. Findings include: Review of Resident #30's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including cellulitis (infection of the skin), type two diabetes, gout, lack of coordination, unsteadiness on feet, and dementia with lewy bodies. Assessment completed on 02/20/22 indicated Resident #30 had severe cognitive impairment. The resident's record additionally revealed Resident #30 admitted to hospice care on 02/07/22. Review of physician orders for Resident #30 revealed an order to, keep elbow protectors in place at all times, dated 01/28/22. It also revealed an order for, bilateral heel lift boots at all times, dated 01/27/22. Observation of Resident #30 throughout the afternoon on 05/09/22 found the 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 · D2022-05-16 · 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 medical record review, resident interview, staff interview, and review of facility policy, the facility failed to provide range of motion as ordered. This affected one resident (#7) of four residents reviewed for positioning and range of motion. The facility census was 89. Findings Include: Review of Resident #7's medical record revealed an admission date of 02/03/22. Diagnoses included adjustment disorder, Alzheimer's disease, and wedge compression fracture of first lumbar vertebra (at admission). Review of Resident #7's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of one indicating Resident #7 was severely cognitively impaired. Resident #7 required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Resident #7 was totally dependent on staff for eating. Resident #7 was receiving therapy services at the time of the review. Resident #7 had delusions during the review period and displayed physical and verbal…
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 · D2022-05-16 · 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 medical record review, staff interview, and review of facility policy, the facility failed to address the nutritional needs of residents with significant weight loss. This affected two residents (#30 and #39) of five residents reviewed for significant weight loss. The census was 89. Findings include: 1. Review of Resident #30's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including cellulitis (infection of the skin), type two diabetes, gout, lack of coordination, unsteadiness on feet, and dementia with lewy bodies. Assessment completed on 02/20/22 indicated Resident #30 had severe cognitive impairment. The resident's record additionally revealed the resident was admitted to hospice care on 02/07/22. Review of Resident #30's weights revealed a weight of 185 pounds on 12/22/21 and 157 pounds on 05/04/22, indicating a significant (15%) weight loss over five months. Resident #30 weighed 173 pounds on 02/09/22 indicating a 12-pound weight loss prior to hospice…
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 · D2022-05-16 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure pharmacy recommendations were timely addressed by the physician. This affected one resident (#7) of five residents reviewed for unnecessary medications. The facility census was 89. Findings Include: Review of Resident #7's medical record revealed an admission date of 02/03/22. Diagnoses included type II diabetes, adjustment disorder, dementia, major depressive disorder, and Alzheimer's disease. Review of Resident #7's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of one, indicating Resident #7 was severely cognitively impaired. Resident #7 had delusions during the review period and displayed physical and verbal behavioral symptoms directed toward others one to three days during the review period. Review of Resident #7's care plan revised 04/08/22 revealed supports and interventions for risk for falls, chronic pain, verbal and physical behaviors,…
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 · D2022-05-16 · tag F0790 — failed to provide dental care — isolatedProvide routine and 24-hour emergency dental care 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 medical record review, resident interview, and staff interview the facility failed to ensure residents received timely dental services. This affected one resident (#83) of one resident reviewed for ancillary services. The facility census was 89. Findings Include: Review of Resident #83's medical record revealed an admission date of 01/04/21. Diagnoses included personal history of COVID-19, dementia and weakness. Review of Resident #83's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of nine, indicating Resident #83 was moderately cognitively impaired. Resident #83 had no oral concerns at the time of the review. Review of Resident #83's care plan revised 04/11/22 revealed supports and interventions for risk for having behaviors of rejection of care, preferences for personal care, and self-care deficit. Review of Resident #83's ancillary services consent form revealed on 07/08/21 Resident #83's representative consented to vision services, dental services,…
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 before2019-06-27 · 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
Based on review of the facility's legionnaires prevention documentation and staff interview, the facility failed to implement a legionella control plan with identified control measures and documentation. This had the potential to affect all the residents residing in the facility. The census was 112. Findings include: Review of a facility policy titled Water Management Plan dated 02/25/18 revealed the facility would conduct a hazard analysis of the water systems and determine which ones present a significant risk of Legionella growth and transmission. Further review revealed the facility would establish control locations where Legionella control measures could be applied. The facility would then establish and implement control measure with performance limits, monitoring, and corrective action. The facility would establish and implement documentation of control measures. Further review of the facility legionnaires documentation revealed no facility assessment which determined specific risk areas for Legionella. The facility had implemented daily tasks, monthly tasks, and yearly tasks…
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 · E2019-06-27 · 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, staff interview, puree recipes, list of residents who received a puree diet and policy and procedures, the facility failed ensure puree menu items were prepared in a manner to conserve the nutritional value. This affected five Residents (#47, #67, #69, #73 and #108) of five resident who received a puree diet in a facility census of 112. Findings include: On 6/26/19 at 10:02 A.M. until 10:22 A.M., [NAME] #200 was observed preparing puree menu items. The first item prepared was stuffing. She was observed preparing a little over five servings of dressing. As she was pureeing the dressing she added approximately a little over two cups of water to reach the desired puree consistency. She then prepared the pork with gravy as a listed menu item for this day. She was observed preparing the five serving of pork chops with five slice of bread. She then added approximately two cups of water and an unmeasured amount of thickener to reach the appropriate puree consistency. On 06/26/19 at 10:22 A.M., interview with [NAME] #200 verified she was not aware of any recipes 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 · D2019-06-27 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility beneficiary notices and staff interview, the facility failed to ensure Medicare beneficiaries received the appropriate notices informing them of their rights when discharged from skilled services. This affected two (Resident #53 and #91) of three residents reviewed for beneficiary notices. The facility census was 112. Findings include: 1. Review of Resident #53's skilled nursing facility beneficiary protection notification form revealed her last covered day of skilled service under Medicare Part A was on 05/02/19. The resident remained in the facility after being discharged from skilled services. Review of the resident's beneficiary notices revealed she did not receive the skilled nursing facility advanced beneficiary notice (SNF ABN) form as required. Interview with the Director of Nursing (DON) on 06/25/19 at 5:55 P.M. verified Resident #53 did not receive a SNF ABN form completed as required. 2. Review of Resident #91's skilled nursing facility beneficiary protection notification form revealed her last covered day of skilled service under Medicare Part…
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 · D2019-06-27 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure a resident, resident's representative, and the ombudsman were notified in writing when a resident was transferred to the hospital. This affected one (Resident #103) of one residents reviewed for hospitalization. The facility census was 112. Findings include: Review of Resident #103's medical record revealed an admission date of 09/25/18. She was transferred to the hospital on [DATE]. Medical diagnoses included candidal cystitis and urethritis, sepsis, osteomyelitis of vertebra, hypertension, end stage renal disease, acute and subacute infective endocarditis, diabetes mellitus, iron deficiency anemia, spinal stenosis, and chronic obstructive pulmonary disease. Continued review of the resident's medical record revealed no indication the resident, the resident's representative, or the ombudsman were notified in writing of the reason for the resident's transfer to the hospital. Interview with the Director of Nursing (DON) on 06/26/19…
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 before2019-06-27 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff interview the facility failed to ensure all treatments were completed as ordered. This affected two residents, (Resident #10 and Resident #92) out of five residents reviewed for treatments. The current census is 112. Findings include: 1. Record review of Resident #10 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #10 include abnormal findings in the lung field, infection of the skin, non-pressure ulcer of the left lower leg, chronic kidney disease, diabetes, edema, and normal pressure hydrocephalus. Review of Resident #10's care plans dated 09/08/15 revealed a focus for impaired skin integrity due to cellulitis and abscess of legs. Interventions for the focus include treatments per order. Review of Resident #10's quarterly Minimum Data Set, (MDS), dated [DATE] revealed the resident had impaired cognition. Per the assessment the resident was documented as having an unhealed, unstageable pressure ulcer and received non-surgical dressing,…
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 · D2019-06-27 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
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, review of facility policy, record review, and staff interview, the facility failed to ensure the proper care and treatment was completed for resident's with tube feedings. This affected one (Resident #41) of one resident reviewed for tube feedings. The current census was 112. Findings include: Record review of Resident #41 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #41 included hypertension, hemiplegia, aphasia, dysphagia, diabetes, convulsions, apraxia, and cerebral vascular accident. Review of Resident #41's physician orders revealed on 03/06/19 an order to check placement and residual of the feeding tube five times a day, to check the placement and residual with each feed five times a day, and to cleanse the peg tube site with normal saline and apply gauze to the site twice a day. Review of Resident #41's care plan dated 03/07/19 revealed a focus feed tube was in place. Interventions included to check tube placement per order and dressing changes…
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 · D2019-06-27 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of a facility policy, the facility failed to ensure an appropriate indication for a resident's antibiotic use. This affected one (Resident #103) of five residents reviewed for unnecessary medications. The facility identified one resident on antibiotic medication. The facility census was 112. Findings include: Review of Resident #101's medical record revealed an admission date of 03/25/19. Medical diagnoses included generalized muscle weakness, insomnia, delusional disorder, cardiac arrhythmia, hemiplegia and hemiparesis following cerebral infarction, atrial fibrillation, cognitive communication deficit, cerebral infarction, and low back pain. Review of the resident's minimum data set assessment dated [DATE] revealed she had moderately impaired cognition. Review of the resident's physician's orders revealed she was started on keflex (antibiotic) 250 milligrams (mgs) three times daily for seven days for a urinary tract infection (UTI) on 06/24/19.…
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
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| WIDMAN, CHRISTOPHER | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/01/1999 |
| DRYFUSE, STEVEN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/11/2022 |
| MACIAS, CRYSTAL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/21/1987 |
| WALTERS, BEAU | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/01/2012 |
CMS files one row per role, so the 9 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
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.
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 365963. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-10-10, 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.