St Catherine's C C Of Fostoria
25 Christopher Dr, Fostoria, OH 44830 · For profit - Corporation · 56 certified beds · (419) 435-8112 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- it has an abuse, neglect, or exploitation citation (F0600), cited May 2023
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $14,433 in federal fines (most recent 2024-02-05)
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) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
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 | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 4.3% | 5.3% | 15.4% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 2.6% | 6.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.6% | 0.2% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.8% | 0.4% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 18.3% | 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 | 0.0% | 3.2% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents whose ability to walk worsened | 3.8% | 6.1% | 16.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 31.4% | 25.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 93.8% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.0% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 31.8% | 21.4% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 14.6% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 3.7% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 47.7% | 75.6% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 23.4% | 24.9% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 17.7% | 12.9% | 12.0% | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ 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.
64.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 54 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 60.9% 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 23 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 0.26 therapist hours per resident per day in 2026Q1 — more than 38% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 13% 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 | 64.4%CMS range 53.2–76.0 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.9%CMS range 7.4–16.2 | 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 | 60.9% | 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 | 60.9% | 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 | 47.8% | 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 | 75.8% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 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 | 0.0% | 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 | 3.0% | 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 | 7.6%CMS range 3.9–15.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.03 | 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 56 beds and averages 46.3 residents a day — about 83% occupied, or roughly 10 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.483 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.87 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.85 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 2.84 hrs/resident/day on weekends vs 3.74 on weekdays — 24% thinner on weekends — a notable drop. RN hours go from 1.06 to 0.41 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 37% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are unchanged from the previous inspection. 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.
22 citations, most serious first. The 11 most serious are shown; the remaining 11 are one tap away and print in full.
- Immediate jeopardy · Jcited before2024-02-05 · 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, review of a facility incident report, review of a staff statement, review of hospital reports, review of a weather report, interviews with staff and Family Member #240, and review of the policy on elopement, the facility failed to provide adequate supervision to prevent Resident #01, who had mild cognitive impairment with recent increased confusion due to a urinary tract infection, from leaving the facility unsupervised and unknown to staff. Additionally, the facility failed to complete a thorough investigation into the elopement incident. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm and/or negative health outcomes when on 01/17/24, sometime after 10:45 P.M., Resident #01 eloped from the facility unsupervised and unknown to staff and was discovered by chance when a pharmacy delivery driver who arrived at the facility around 10:55 P.M. found the resident locked outside the facility and bleeding from the hand while standing on the porch.…
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 before2026-03-26 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to store, label, date, and maintain food in a manner to prevent contamination and spoilage in accordance with acceptable food safety practices. This deficient practice had the potential to affect all residents, as all facility residents received food prepared and distributed from the facility kitchen. The facility census was 52. Findings include: During a tour of the facility kitchen on 03/23/26 at 8:05 A.M., 10 four-ounce containers of cucumber and tomato salad were observed in the kitchen's free-standing refrigerator that were unlabeled and undated with the date of preparation. An approximately one-half full, three-quart container of ketchup was also observed to be unlabeled and undated with the date opened.Interview on 03/23/26 at 8:06 A.M. with Nutrition Services Assistant (NSA) #210 verified the 10 four-ounce containers of cucumber and tomato salad were unlabeled and undated. NSA #210 stated the items were prepared on 03/20/26. NSA #210 also verified the three-quart container of ketchup was one-half full…
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 · D2026-03-26 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, review of facility shower schedule, and medical record review, the facility failed to ensure a resident who was not dependent on staff for activities of daily living received bathing services as scheduled. This affected one resident (#44) of three residents (#30, #41, and #44) reviewed for Activities of Daily Living (ADLs). The facility census was 52. Findings Include: Review of the medical record for Resident #44 revealed an admission date of 01/29/26 with diagnoses including atrial fibrillation, hypokalemia, hypertension (HTN), anxiety, depression, other idiopathic peripheral autonomic neuropathy, post-traumatic stress disorder (PTSD), cervical spinal stenosis, obstructive sleep apnea, abnormal weight loss, solitary pulmonary nodule, attention and concentration deficit, frontal lobe and executive function deficit, palpitations, personal history of transient ischemic attack (TIA), and cerebral infarction.Review of the admission Minimum Data Set (MDS) assessment, dated 02/10/26, revealed a Brief Interview of Mental Status (BIMS) score of 15,…
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 · D2026-03-26 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, medical record review, and review of facility policy, the facility failed to provide necessary assistance with personal hygiene to maintain grooming and cleanliness for one resident (#41) of three residents (#30, #41, and #44) reviewed for activities of daily living (ADLs). The facility census was 52. Findings Include: Review of the medical record for Resident #41 revealed an admission date of 05/06/20 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting non-dominant side, chronic obstructive pulmonary disease (COPD), Type Two Diabetes Mellitus (DM2), vascular dementia, aphasia following cerebral infarction, hypertensive heart and chronic kidney disease with heart failure, congestive heart failure (CHF), epilepsy, atrial fibrillation, stage three chronic kidney disease (CKD3), osteoporosis, major depressive disorder, hyperlipidemia, anemia, diverticulitis, ventral hernia, constipation, atopic dermatitis, other long-term (current) drug therapy, allergic rhinitis, long-term use of anticoagulants, and…
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 before2026-03-26 · 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 record review, staff interview, observation of wound care, and policy review, the facility failed to timely assess and treat a pressure ulcer. This affected one resident (#8) of three residents reviewed for pressure ulcers. The facility census was 52. Findings include:Review of Resident #8's medical record revealed an initial admission date of 07/25/25 and a re-entry date of 08/07/25. Diagnoses included metabolic encephalopathy, Chronic Obstructive Pulmonary Disease (COPD) with acute exacerbation, acute respiratory failure with hypercapnia, hypertensive chronic kidney disease, and a pressure ulcer of the sacral region stage four (full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling). Review of Resident #8's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 15. Furthermore, Resident #8…
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 · D2026-03-26 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and staff interview, the facility failed to ensure a catheter securement device was utilized for one resident (#4) of three residents reviewed for catheter securement devices. The facility census was 52. Findings include:Review of Resident #4's medical record revealed an admission date of 01/07/26. Diagnoses included nontraumatic intracranial hemorrhage, hypertensive heart disease with heart failure, neuromuscular dysfunction of the bladder, benign prostatic hyperplasia with lower urinary tract symptoms, and peripheral vascular disease. Review of Resident #4's Modification of admission Minimum Data Set (MDS) assessment dated [DATE] revealed resident #4 had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of 12. Resident #4 was coded to have an indwelling urinary catheter. Review of Resident #4's physician's orders revealed an order with a start date of 02/03/26 for indwelling catheter care every shift related to other retention of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-26 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure personal protective equipment (PPE) was applied during resident care as required and enhanced barrier precautions were in place. This affected two (#4,and #8) of three residents reviewed for enhanced barrier precautions. The facility census was 52. Findings include: 1. Review of Resident #4's medical record revealed an admission date of 01/07/26. Diagnoses included nontraumatic intracranial hemorrhage, hypertensive heart disease with heart failure, neuromuscular dysfunction of the bladder, benign prostatic hyperplasia with lower urinary tract symptoms, and peripheral vascular disease. Review of Resident #4's Modification of admission Minimum Data Set (MDS) assessment dated [DATE] revealed resident #4 had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of 12. Further review revealed Resident #4 had an indwelling urinary catheter. Review of Resident #4's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-21 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and facility policy review the facility failed to ensure prescribed medications were with the resident on discharge. This affected one Former Resident ( #52) of three former residents (#52, #53, #54) reviewed for discharge. The facility census was 42. Summary of findings: Review of Former Resident (FR) #52's medical record revealed an admission date of 02/24/25 and discharged on 03/03/25. Diagnosis included acute kidney failure, acute respiratory distress syndrome, bacteremia, sacral pressure ulcer, congestive heart failure, and atrial fibrillation. Review of FR #52's discharge Minimum Data Set (MDS) dated [DATE] revealed the resident had an intact cognition. She was dependent for all activities of daily living. Review of FR #52's care plan revealed she wished to return home with family after respite stay. Review of FR #52's medical record revealed she required Acetaminophen (pain), Albuterol nebulizer solution (shortness of breath), Colace (constipation), Eliquis (blood…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-21 · 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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, staff interview, and facility policy review, the facility failed to adequately monitor a resident's (Former Resident #52) wound on admission the throughout her stay. The facility census was 42. Findings included: Review of Former Resident (FR) #52's medical record revealed an admission date of 02/24/25 and discharged on 03/03/25. Diagnosis included Stage IV sacral pressure ulcer (Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.), acute kidney failure, acute respiratory distress syndrome, bacteremia, congestive heart failure, and atrial fibrillation. Review of FR #52's discharge Minimum Data Set (MDS) dated [DATE] revealed the resident had an intact cognition. She was dependent for all activities of daily living. Review of FR #52's medical record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-21 · 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 interview, and policy review, the facility failed to ensure a resident was supervised for eating. Resident #19 obtained and ate whole food when ordered a pureed diet, choked, received the Heimlich maneuver, and was admitted to the hospital. This deficient practice affected one resident (#19) of three reviewed (#11 and #24) for choking. In addition, two residents (#19, #53) of four reviewed (#11 and #24) failed to have fall precautions in place which resulted in falls. The facility census was 42. Findings included: 1 - Review of Resident #19's medical record revealed an admission date of 01/18/15. Diagnosis included cerebral vascular accident, schizoaffective disorder, epilepsy, mild intellectual disabilities, and congestive heart failure. Review of Resident #19's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a moderately intact cognition. The resident had coughing or choking during meals or when swallowing medications along with complaints of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-04-04 · 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 facility policy review, the facility failed to ensure foods and cooking equipment were maintained in a clean and sanitary manner. This had the potential to affect all 36 residents receiving food from the kitchen as the the facility identified no residents who received nothing by mouth. The facility census was 36. Findings include: Observation on 04/01/24 between 8:15 A.M. and 8:30 A.M. during the initial tour of the kitchen revealed the walk-in freezer contained greater than 10 boxes of frozen food sitting on the floor of the freezer. Further review revealed a food cart with two trays of left over, uncovered, undated cherry pies. Interview on 04/01/24 at 8:25 A.M. with Dietary Manager (DM) #277 verified the greater than 10 boxes of frozen food on the floor in the walk-in freezer and the left over pies on the cart that were left unattended. Further interview with DM #277 stated the items on the floor of the walk-in freezer were from the product delivery on Friday, 03/29/24. Follow-up observation on 04/03/24 at 10:15 A.M. in the kitchen…
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 11 citations
- Potential for harm · E2024-04-04 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, resident and staff interview, and policy review, the facility failed to maintain the facility environment in a clean, safe, and functional manner. This affected five (#4, #17, #22, #32, and #86) of six residents reviewed for environment. The facility census was 36. Findings include 1. Review of the medical record revealed Resident #86 had an admission date of 08/09/23. Diagnoses included dementia, chronic obstructive pulmonary disease, and hypertension. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #86 had impaired cognition. Observation on 04/01/24 at 9:37 A.M. revealed there were four red circular stains on Resident #86's ceiling, multiple stains on the privacy curtain, and the window ledge was loose. Interview on 04/03/24 at 10:30 A.M., with Environmental Services Supervisor (ESS) #222 verified the stains on the resident's ceiling and privacy curtain. ESS #222 also verified the loose window ledge in the resident's room. 2.…
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 · D2024-04-04 · 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, resident and staff interview, and medical record review, the facility failed to maintain resident dignity of by not covering a urinary catheter collection bag. This affected one (#8) of one residents reviewed for dignity. The facility census was 36. Findings include: Review of the medical record for Resident #8 revealed an admission date of 04/17/20 with diagnoses of obstructive uropathy and reflux uropathy, hematuria (blood in the urine), and urinary retention. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #8 revealed the resident required an indwelling catheter. Review of the physician orders for April 2024 for Resident #8 revealed the resident was ordered an indwelling urinary (Foley) catheter with instructions to change as needed to maintain patency and catheter care every shift and as needed. Review of the care plan revised January 2024 for Resident #8 revealed the resident was care planned for an indwelling urinary catheter with an intervention 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 · Dcited before2024-04-04 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
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 and staff interview, review of shower schedules, and policy review, the facility failed to honor a resident's preference for bathing on scheduled days. This affected one (#26) of one resident reviewed for choices. The facility census was 36. Findings include: Review of Resident #26's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic kidney disease, hyperlipidemia, hypertension, and morbid obesity. Review of Resident #26's quarterly Minimum Data Set assessment, dated 02/21/24, revealed the resident was assessed as cognitively intact and with no exhibited behaviors such as rejection of care. The resident was dependent on staff for bathing and personal hygiene. Review of the facility's shower schedule revealed Resident #26 was scheduled to be showered on the evening shift every Tuesday and Saturday. Review of Resident #26's electronic medical record and shower sheets revealed the resident did not receive showers on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-04 · 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 observation, medical record review, and resident and staff interview, the facility failed to ensure hearing aids were offered to maintain adequate hearing. This affected one (#16) of one residents reviewed for hearing. The facility census was 36. Findings include: Review of the medical record revealed Resident #16 had an admission dated of 05/06/20. Diagnoses included type two diabetes mellitus, hemiplegia and hemiparesis following cerebral infarction, chronic kidney disease, and atrial fibrillation. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 had impaired cognition and the resident was assessed as not having hearing aids. Review of an audiology consultation report dated 08/22/22 revealed Resident #16 had bilateral moderate to moderately severe sensorineural hearing loss. Review of the care plan dated 09/01/22 revealed to encourage Resident #16 to wear hearing aids, although she refused to wear bilateral hearing aids. Review of Resident #16's current…
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 · D2024-04-04 · 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, resident and staff interview, and medical record review, the facility failed to ensure range of motion (ROM) devices were in place as ordered. This affected one (#8) of one residents reviewed for range of motion. The facility census was 36. Findings include: Review of the medical record for Resident #8 revealed an admission date of 04/17/20 with diagnoses of hemiplegia and hemiparesis (partial and full weakness) following a cerebral infarct (stroke) affecting the left side. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #8 revealed she was cognitively intact and was dependent on staff for dressing, toileting, bed mobility, and personal hygiene. Review of Resident #8's physician orders for April 2024 revealed an order for an elbow extension brace to the left elbow on at all times when the resident was in bed. Review of the care plan revised January 2024 for Resident #8 revealed the resident was care planned for an elbow extension brace to the left elbow…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-05-04 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, resident and staff interviews, and review of shower schedules, the facility failed to ensure resident choice for activities of daily living (ADLs) was honored. This affected two (#35 and #197) of five residents reviewed for ADLs. The facility census was 38. Findings included: 1. Review of Resident #35's medical record revealed admission to the facility occurred on 04/28/23. Resident #35 was in the facility from 02/24/23 through 03/23/23 and 03/26/23 through 04/25/23. Resident #35 had medical diagnoses including pulmonary high blood pressure, anxiety, and obstructive sleep apnea. Review of Resident #35's admission assessment dated [DATE] revealed he was cognitively intact and he required extensive assistance of one person with physical help needed for bathing. The assessment preference section identified Resident #35 indicated it was very important for him to choose between a tub bath, shower, or bed/sponge bath. Review of the facility's shower schedule, provided by…
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 · D2023-05-04 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of a self-reported incident, resident and staff interviews, and review of an abuse policy, the facility failed to prevent resident to resident abuse. This affected two (#18 and #29) of two residents reviewed for abuse. The census was 38. Findings include: 1. Review of Resident #18's medical record revealed an admission date of 09/26/12. Diagnoses included major depressive disorder, hemiplegia and hemiparesis affecting the left non-dominant side, hypertension, and anxiety. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #18 had intact cognition. Resident #18 required the extensive assistance of two staff for bed mobility and the extensive assistance of one staff for transfers. The resident was independent with moving around the facility in a wheelchair. Review of the plan of care for Resident #18, revised on 07/20/22, revealed Resident #18 had the potential to demonstrate verbally and physically abusive behaviors related to poor…
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 · D2023-05-04 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of a self-reported incident (SRI), staff interview, and review of an abuse policy, the failed to thoroughly investigate an allegation of abuse. This affected two (#18 and #29) of two residents reviewed for abuse. The facility census was 38. Findings include: Review of a self-reported incident (SRI), with Tracking #234245, revealed on 04/20/23 at 8:55 P.M., Resident #18 struck Resident #29 in the face. The SRI identified there were three residents (#18, #22, and #29) sitting in a circle when this occurred. The SRI included no statements or interviews with other residents who resided in the area or all the staff working at that time. The SRI included interviews with Resident #18, Resident #22, and Resident #29 and a statement Registered Nurse (RN) #231 who was working at the time of the incident. The facility concluded abuse occurred following their investigation. Interview with the Administrator on 05/03/23 at 8:26 A.M. confirmed the facility did not interview any other residents following the 04/20/23 incident between Resident #18 and Resident #29 to ensure no other…
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 · D2023-05-04 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, resident and staff interviews, and policy review, the facility failed to have a physician order for respiratory services and equipment. This affected one (#35) of one resident review for respiratory services. The facility census was 38. Findings include: Review of Resident #35's medical record revealed admission to the facility occurred on 04/28/23. Resident #35 was in the facility from 02/24/23 through 03/23/23 and 03/26/23 through 04/25/23. Resident #35 had medical diagnoses including pulmonary high blood pressure, anxiety, and obstructive sleep apnea. Review of Resident #35 hospital records dated 02/16/23 revealed he used a bilevel positive airway pressure (BiPap) device for obstructive sleep apnea, interstitial lung disease, severe pulmonary hypertension, and oxygen on exertion. Review of Resident #35's admission assessment dated [DATE] identified he was cognitively intact. Observation and interview with Resident #35 on 05/01/23 at 10:10 A.M. revealed Resident #35…
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 · D2023-05-04 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure a blood pressure medication was administered per physician orders. This affected one (Resident #27) of three residents observed for medication administration. The facility census was 38. Findings include Review of the medical record revealed Resident #27 had an admission date of 11/03/21. Diagnoses included atrial fibrillation, congestive heart failure, hypertension, type two diabetes mellitus and cardiomyopathy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had intact cognition. Review of Resident #27's physician orders revealed a physician order dated 04/21/23 revealed to decrease the blood pressure medication metoprolol to 25 milligrams (mg) daily and hold if the systolic blood pressure was less than 100 millimeters of mercury (mmHg) or heart rate was less than 60 beats per minute. Observation on 05/02/23 at 8:38 A.M. revealed Resident #27's blood…
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 · D2023-05-04 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview with staff and residents, review of resident medical records, review of meal tickets, and review of the menu, the facility failed to accommodate food-related allergies. This affected two (#8 and #40) of four residents reviewed for food allergies. The census was 38. Findings include: 1. Review of the medical record for Resident #8 revealed the resident was admitted on [DATE] and had diagnoses that included Parkinson's disease, schizophrenia, major depressive disorder, and anxiety. The medical record identified an allergy to alcohol on the home page screen and the allergy page. The record included a physician order for a calorie-restricted, mechanical soft diet. Review of the Minimum Data Set (MDS) 3.0 assessment for Resident #8, dated 04/12/23, revealed the resident had a moderate degree of cognitive impairment. 2. Review of Resident #40's medical record revealed admission to the facility occurred on 04/29/23 with medical diagnoses including Alzheimer's disease, urine retention, and a dehisced…
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
$14,433 in federal fines across 1 penalty.
- $14,433 — penalty dated 2024-02-05
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 HCF MANAGEMENT — 22 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.1 | -0.1 vs chain |
| Health inspection | 3 of 5 | 2.9 | +0.1 vs chain |
| Staffing | 3 of 5 | 2.8 | +0.2 vs chain |
| Quality measures | 4 of 5 | 4.1 | ≈ chain avg |
The other 21 homes this chain runs (chain average 3.1★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| CHAD M. UNVERFERTH 12-14-11 IRRV GRANTOR TR | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 6% | since 12/13/2021 |
| DAVID V. UNVERFERTH 12-14-11 IRRV GRANTOR TR | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 6% | since 12/13/2021 |
| JEFFREY L. UNVERFERTH 12-14-11 IRRV GRANTOR TR | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 6% | since 12/13/2021 |
| JOANN C. UNVERFERTH 12-29-04 REVOCABLE TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 5% | since 12/13/2021 |
| JOANN C. UNVERFERTH 12-31-12 IRREVOCABLE GRANTOR TRUST FBO KENDRA M. U | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 7% | since 12/13/2021 |
| JOANN C. UNVERFERTH 12-31-12 IRREVOCABLE GRANTOR TRUST FBO KERRI A. RO | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 7% | since 12/13/2021 |
| JOANN C. UNVERFERTH 12-31-12 IRREVOCABLE GRANTOR TRUST FBO KEVAN R. UN | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 7% | since 12/13/2021 |
| JOANN C. UNVERFERTH 12-31-12 IRREVOCABLE GRANTOR TRUST FBO KRISTEN S. | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 7% | since 12/13/2021 |
| JOANN C. UNVERFERTH 12-31-12 IRREVOCABLE GRANTOR TRUST FBO KYLE J. UNV | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 7% | since 12/13/2021 |
| JOSEPH L. UNVERFERTH 12-15-11 IRRV GRANTOR TR | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 6% | since 12/13/2021 |
| LAWRENCE G. UNVERFERTH 12-13-11 IRRV GRANTOR TR | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 6% | since 12/13/2021 |
| R. STEVEN UNVERFERTH 12-14-11 IRRV GRANTOR TR | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 6% | since 12/13/2021 |
| BLIGHTON, STEFANIE | Individual | W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR | — | since 04/29/2024 |
| KLAY, CELESTE | Individual | W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 01/01/2016 |
| ROMES, KERRI | Individual | W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 03/29/2019 |
| SHAW, ANTHONY | Individual | W-2 MANAGING EMPLOYEE; CORPORATE OFFICER | — | since 06/26/2015 |
| UNVERFERTH, CHAD | Individual | W-2 MANAGING EMPLOYEE; CORPORATE OFFICER | — | since 03/17/2003 |
| HCF MANAGEMENT, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 05/01/2008 |
CMS files one row per role, so the 25 rows in the source record cover these 18 parties — each is shown once here with every role it holds. Nothing is omitted.
13 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 $202K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OH
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Ohio Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 365575. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-26, 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.