Meadowbrook Manor
3090 Five Points Hartford, Fowler, OH 44418 · For profit - Corporation · 54 certified beds · (330) 772-5253 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 Apr 2026
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0569)
- 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 $24,850 in federal fines (most recent 2025-05-29)
- its facility-reported quality-measure score sits well above its independent inspection score
- its payroll-based staffing rating is low (1/5)
- nursing-staff turnover (69%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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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 fell from 4 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 6.5% | 5.3% | 15.4% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 3.4% | 6.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.2% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.4% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 31.8% | 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 | 2.4% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 1.3% | 6.1% | 16.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 40.0% | 25.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 97.7% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.1% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 27.9% | 21.4% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 6.2% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 76.3% | 75.6% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 14.4% | 24.9% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 14.2% | 12.9% | 12.0% | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
46.3% 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 32 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.23 therapist hours per resident per day in 2026Q1 — more than 29% 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 | 46.3%CMS range 33.4–63.2 | 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 | 9.3%CMS range 5.9–13.6 | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.00 | 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 54 beds and averages 48.0 residents a day — about 89% occupied, or roughly 6 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.12 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.38 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.75 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 2.77 hrs/resident/day on weekends vs 3.26 on weekdays — 15% thinner on weekends. RN hours go from 0.41 to 0.29 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 69% is well above 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 more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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 · J2025-07-08 · tag F0627 — isolatedEnsure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed medical record review, review of the facility Resident Transfer and Discharge Policy and interviews, the facility failed to provide a safe discharge to an appropriate location for Resident #49. On 05/20/25 Resident #49 was discharged to a homeless shelter with no referral for follow up care, no access to transportation and no evidence the resident's representative/emergency contact was involved in the discharge planning process or aware of the resident's discharge to the homeless shelter. In addition, there was no evidence Resident #49 was safe to discharge to this location. Upon arrival to the shelter, staff at the shelter identified Resident #49 was not appropriate to remain there and the resident voiced she wanted to return to the facility; however, the facility failed to allow the resident to return. This resulted in Immediate Jeopardy and the potential for actual harm, injury or death beginning on 07/01/25 when Resident #49's, who had diagnoses including diabetes, chronic obstructive…
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 · F2026-04-28 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and review of staffing schedules, the staffing tool and the facility assessment, the facility failed to ensure a registered nurse (RN) was in the facility at least eight consecutive hours a day, seven days a week. This had the potential to affect all 50 residents residing at the facility.Findings include: Review of staffing schedules from 01/01/26 to 04/21/26 revealed there was no RN coverage for at least eight consecutive hours on 01/24/26 and 04/05/26. Review of the staffing tool from 04/05/26 to 04/11/26 completed on 04/21/26 at 12:00 P.M. with Administrator, Human Resource (HR) #624, and Scheduler/HR Assistant #623 revealed there was no RN coverage for at least eight consecutive hours on 04/05/26. Interview on 04/21/26 at 12:00 P.M. and 1:47 P.M. with Administrator, HR #624, and Scheduler/HR Assistant #623 verified per the staffing schedules from 01/01/26 to 04/21/26 and the staffing tool completed from 04/05/26 to 04/11/26, there was no RN coverage for at least eight consecutive hours…
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 · Ddisputed · IDR2026-04-28 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and review of Self-Reported Incident (SRI) #268530, the state survey agency database for SRI reporting, the facility investigation and facility policy, the facility failed to ensure residents were free from sexual abuse. This affected three residents (Resident #22, #53 and #54) out of six residents reviewed for abuse. The facility census was 50.Findings include: 1. Review of the medical record for Resident #22 revealed she had an admission date of 06/06/25 and her diagnoses included Alzheimer's disease, hypertension, and major depression. She had a friend listed as Power of Attorney (POA) for finance and per the facility the friend did not want involvement in her healthcare decisions. There was not a POA of healthcare and/or guardian listed. There was nothing in her medical record regarding if Resident #22 was evaluated whether she had the capacity to consent to sexual activity. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] (prior to incident) revealed…
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 · Ddisputed · IDR2026-04-28 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and review of Self-Reported Incident (SRI) #268530, the state survey agency database for SRI reporting, the facility investigation and facility policy, the facility failed to report to the state survey agency and/or local law enforcement an allegation of sexual abuse. This affected two residents (Residents #22 and #53) out of six residents reviewed for abuse. The facility census was 50.Findings include: 1. Review of the medical record for Resident #22 revealed she had an admission date of 06/06/25 and her diagnoses included Alzheimer's disease, hypertension, and major depression. She had a friend listed as Power of Attorney (POA) for finance and per the facility the friend did not want involvement in her healthcare decisions. There was not a POA of healthcare and/or guardian listed. There was nothing in her medical record regarding if Resident #22 was evaluated whether she had the capacity to consent to sexual activity. Review of the admission Minimum Data Set (MDS) assessment…
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 beforedisputed · IDR2026-04-28 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and review of Self-Reported Incident (SRI) #268530, the facility investigation and facility policy, the facility failed to ensure preventative measures were implemented to prevent sexual abuse. This affected three residents (Residents #22, #53 and #54) out of six residents reviewed for abuse. The facility census was 50. Findings include: 1. Review of the medical record for Resident #22 revealed she had an admission date of 06/06/25 and her diagnoses included Alzheimer's disease, hypertension, and major depression. She had a friend listed as Power of Attorney (POA) for finance and per the facility the friend did not want involvement in her healthcare decisions. There was not a POA of healthcare and/or guardian listed. There was nothing in her medical record regarding if Resident #22 was evaluated whether she had the capacity to consent to sexual activity. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] (prior to incident) revealed Resident #22's Brief…
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 · D2026-04-28 · tag F0745 — failed to provide medically-related social services — isolatedProvide medically-related social services to help each resident achieve the highest possible quality of life.
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, interview, and review of Self-Reported Incident (SRI) #268530 and the facility investigation, the facility failed to ensure Resident #22 was provided medically related social service to attain the highest practicable wellbeing by seeking guardianship to assist with decision making. This affected one resident (Resident #22) out of six residents reviewed for social service needs. This had the potential to affect four residents (Residents #15, #18, #22 and #37) who were identified by the facility as residents unable to make informed decisions without a guardian and/or responsible party. The facility census was 50. Findings include: Review of the medical record for Resident #22 revealed she had an admission date of 06/06/25 and her diagnoses included Alzheimer's disease, hypertension, and major depression. She had a friend listed as Power of Attorney (POA) for finance and per the facility the friend did not want involvement in her healthcare decisions. There was not a POA of healthcare and/or…
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 · D2026-04-28 · 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 record review, interview, and review of facility policy, the facility failed to ensure residents were free of significant medication errors by providing residents with antibiotic (ATB) therapy in a timely manner and in accordance with physician orders. This affected two residents (Residents #39, and #51) out of three residents reviewed for ATB therapy. The facility census was 50.Findings include: 1. Review of the medical record for Resident #51 revealed an admission date of 10/16/25 and he was discharged to the hospital on [DATE]. His diagnoses on admission included enterocolitis due to Clostridium Difficile (C-Diff) (a highly contagious bacterium that causes severe diarrhea and inflammation of colon), hypertension, malignant neoplasm of the prostate, and chronic kidney disease.Review of October 2025 physician orders revealed Resident #51 had an order dated 10/16/25 for fidaxomicin (ATB) oral tablet 200 milligram (mg) give one tablet by mouth every morning and at bedtime for five days due to C-Diff.…
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 before2025-08-28 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, facility self-reported incident (SRI) and investigation review, the facility failed to ensure a SRI was thoroughly investigated related to an allegation of resident-to-resident sexual abuse. This affected two residents (#16 and #49) of five residents reviewed for abuse. The facility census was 47. Findings include: 1. Review of the medical record for Resident #16 revealed an admission date of 05/06/24. Diagnoses included dementia, diabetes, chronic obstructive pulmonary disease (COPD), kidney disease, restlessness and agitation, and anxiety. Review of the care plan dated 05/01/25 revealed Resident #16 wandered up and down hallways and into other resident's rooms. Interventions included engaging the resident in activities, moving him into a less stimulating area and redirecting him as needed. Resident #16 also made sexually inappropriate advances towards staff members and mistook a female resident as his wife, becoming verbally and physically aggressive when redirected.…
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 · D2025-08-28 · 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 record review, interview and facility policy review, the facility failed to ensure Resident #16, who was cognitively impaired and had a history of wandering and sexually inappropriate behaviors, received appropriate supervision to ensure the safety of Resident #49. This affected two residents (#16 and #49) of five reviewed for abuse and behavior monitoring. The facility census was 47. Findings include: 1. Review of the medical record for Resident #16 revealed an admission date of 05/06/24. Diagnoses included dementia, diabetes, chronic obstructive pulmonary disease (COPD), kidney disease, restlessness and agitation, and anxiety. Review of the care plan dated 05/01/25 revealed Resident #16 wandered up and down hallways and into other resident's rooms. Interventions included engaging the resident in activities, moving him into a less stimulating area and redirecting him as needed. Resident #16 also made sexually inappropriate advances towards staff members and mistook a female resident as his wife,…
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 · E2025-05-29 · tag F0558 — failed to accommodate residents' needs and preferences — patternReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, record review, and review of facility policy, the facility failed to ensure call lights were within reach of Resident #3, #27, #34 and #43. This affected four residents of 19 residents reviewed for accommodation of need. The facility census was 47. Findings include: 1. Review of the medical record for Resident #3 revealed an admission date of 11/07/24 with diagnoses including hemiplegia and hemiparesis following cerebral infarction (stroke), hemiplegia affecting right dominant side, major depressive disorder, and insomnia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/13/25, revealed Resident #3 was moderately impaired cognitively, had upper and lower extremity impairment on one side, was dependent on staff for all activities of daily living except required substantial/maximum assistance from staff for eating, required substantial/maximum assistance to roll left and right, was independent for maneuvering his motorized wheelchair, was always incontinent of bowel and bladder and had two or more falls without major injury…
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 · D2025-05-29 · tag F0569 — isolatedNotify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, interview and policy review, the facility failed to refund resident funds within 30 days of discharge. This affected two residents (#253 and #254) of six residents (#2, #5, #15, #24, #253 and #254) reviewed for resident funds. The facility census was 47. Findings include: 1. Review of resident records for Resident #253 revealed an initial admission date of 09/12/14 and a discharge date of 11/15/24. Diagnosis included schizoaffective disorder bipolar type. A review of the face sheet for Resident #253 revealed they had a court appointed guardian. Review of the discharge Minimum Data Set (MDS) assessment revealed Resident #253 had severe cognitive impairment. Review of the facility document titled Resident Fund Authorization revealed resident #253 authorized the facility to hold, safeguard and account for personal funds. The document was signed by Resident #253 on 09/08/15. On 05/28/25 at 11:00 A.M. a review of the resident fund account for Resident #253 revealed on 01/07/25 the facility distributed check #1901 in the amount of $5,588.60 to the guardian 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.
Show the remaining 11 citations
- Potential for harm · D2025-05-29 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview and policy review the facility failed to ensure a bed alarm assessment was completed prior to implementing a bed alarm for Resident #46. This affected one resident (Resident #46) of two residents reviewed for bed alarms. The facility identified two residents (#46 and #33) ordered bed alarms. The facility census was 47. Findings include: A review of medical records for Resident #46 revealed an admission date of 02/20/25 with pertinent diagnoses including Alzheimer's disease, major depressive disorder, repeated falls, vascular dementia and anxiety. Significant Review of physician orders included Buckeye Hospice admission dated 05/27/25 and bed alarm to remind resident not to get up unassisted dated 05/23/25. Review of an admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #46 had severe cognitive impairment. The MDS also revealed a history of falls in the last month prior to admission. There was no alarm usage noted within the MDS. Review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-29 · tag F0847 — isolatedInform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, interviews and observation, the facility did not ensure Resident #1, Resident #20 and Resident #37 were explicitly informed of their right to not sign a binding arbitration agreement and were given the option to not sign the binding arbitration agreement. This affected three residents (#1, #20 and #37) out of five residents reviewed for arbitration agreements. The facility identified 35 residents (#1, #2, #3, #5, #6, #8, #10, #11, #13, #17, #18, #19, #20, #21, #22, #23, #25, #27, #30, #32, #33, #34, #37, #38, #39, #41, #42, #43, #45, #46, #47, #49, #50, #103, and #104) with a binding arbitration agreement. The facility census was 47. Findings include: 1. Review of the medical record for Resident #37 revealed an admission date of 01/02/25. Diagnoses included transverse myelitis in demyelinating disease of the central nervous system, type two diabetes, functional quadriplegia, acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure, anxiety disorder, and persistent mood disorders. Review of Resident #37's Minimum Data Set (MDS)…
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 · D2024-10-09 · tag F0661 — isolatedEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility did not ensure a complete summary of discharge was provided to Resident #27 for continuation of necessary care and services at home. This effected one resident (Resident #27) of three residents reviewed for discharge. The facility census was 26. Findings include: Review of the medical record revealed Resident #27 was admitted to the facility on [DATE] and discharged home on [DATE]. Medical diagnoses included pressure induced deep tissue damage of the back, buttocks and hip, paraplegia, immobile, bacteremia, pressure ulcer right heel stage four, chronic pain, neuromuscular dysfunction of bladder, anemia, sacral ulcer stage four, hip dislocation, anxiety, protein calorie malnutrition, sepsis, colostomy, and need for assistance for personal care. Review of the Minimum Data Set (MDS) 3.0 admission assessment dated [DATE] revealed Resident #27 entered the facility on 07/19/24 from a hospital. Resident #27 had good cognition. Lower extremity range of motion was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2022-11-23 · tag F0809 — failed to serve meals on a reasonable schedule — widespreadEnsure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on meal schedule review, menu review, staff interview, and observation, the facility failed to provide a substantial evening snack when greater than 14 hours elapsed between the evening meal and breakfast. This had the potential to affect 33 out of 33 residents that received meals from the kitchen. The facility census was 33. Findings include: Review of scheduled mealtimes revealed dinner was at 4:45 P.M. for the second floor and at 5:05 P.M. for the first floor, and breakfast was at 7:30 A.M. for the second floor and 7:50 A.M. for the first floor. Review of the 11/20/22 to 11/26/22 facility menus revealed evening snacks were not listed on the menu. Interview on 11/22/22 at 9:00 A.M. with Dietary Supervisor #407 revealed the facility filled two rectangular plastic containers with lids with peanut crackers, cheese curls, short bread cookies, and occasional left-over muffins. The plastic containers were placed behind the nurse's stations on each of the two floors of the facility. A dietary employee checked the containers at 10:00 A.M. and 3:00 P.M. to see if they needed…
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 · D2020-01-02 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the 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 record review, interview and review of facility policy and procedure the facility failed to notify the physician when Resident #19's blood sugar was above 350 per physician order. This affected one resident (Resident #19) out of two residents reviewed for unnecessary medication that received glucometer checks. This had the potential to affect seven residents (Resident #10, #19, #20, #21, #27, #131, and #181) that received blood sugar checks per glucometer. The facility census was 28. Findings include: Review of the medical record for Resident #19 revealed an admission date of 06/21/19 and diagnoses that included diabetes, chronic kidney disease, and spinal stenosis. Review of the care plan dated 09/03/19 revealed Resident #19 had diabetes. Interventions included diabetes medications as ordered by the physician, monitor, document, and report to the physician as needed signs and symptoms of hypoglycemia and hyperglycemia (low/high blood sugar). Review of the quarterly minimum data set (MDS) assessment…
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 · D2020-01-02 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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 record review, interview and observation the facility failed to ensure Resident #20's wheelchair was maintained in safe condition. This affected one of 28 residents observed for environment. The facility census was 28. Findings include: Resident #20 was admitted to the facility on [DATE] with diagnoses including heart failure, morbid obesity and diabetes mellitus type two. Review of the Plan of Care with an initial date of 08/08/19 revealed he was at risk for skin breakdown due to his morbid obesity and diabetes mellitus type two. The Minimum Data Set assessment (MDS) dated [DATE] revealed he had cognitive impairment, needed limited assistance of one person for bed mobility and transfers and extensive assistance of one person for toileting, dressing and hygiene. He was able to move on an off the unit using his wheelchair. Observation was conducted on 12/30/19 at 9:26 A.M. of Resident #20 sitting in the hallway. The right arm of his wheelchair was missing the padded covering exposing the bare metal.…
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 · D2020-01-02 · 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, interview, and review of policy the facility failed to develop a baseline care plan with the minimum necessary mental health information for Resident #181. This affected one (Resident #181) of one resident reviewed for baseline care plan. Findings include: Resident #181 was admitted to the facility on [DATE]. His diagnoses included paranoid schizophrenia, chronic post-traumatic stress disorder, recurrent major depressive disorder, generalized anxiety disorder, and mild cognitive impairment. Review of physician orders dated 12/20/19 revealed the resident was to receive trazodone (antidepressant) 25 milligrams (mg) daily for insomnia and Clozaril (antipsychotic) 100 mg twice a day for schizophrenia. Review of physician orders dated 12/21/19 revealed citalopram (antidepressant) 10 mg daily for depression was added. Review of the Ohio Department of Mental Health Pre-admission Screen and Resident Review (PASRR) Determination for Resident #181 revealed a list of information important for the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2020-01-02 · 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 interview, and record review the facility failed to ensure they monitored frequency of bowel movements, and developed and implemented a bowel management protocol to prevent constipation for Resident #21. This affected one (Resident #21) of one resident reviewed for constipation and had the potential to affect all 29 residents currently residing in the facility. Findings include: Review of medical record for Resident #21 revealed an admission date of 10/22/19 and diagnoses included morbid obesity, diabetes, pressure ulcer of the sacral region, muscle weakness, and constipation. Review of an admission five-day minimum data set (MDS) dated [DATE] revealed Resident #21 had intact cognition. She was totally dependent on one person for bed mobility and transfers occurred only once or twice with two person assist. She was unable to ambulate. She was totally dependent on two persons with toileting and was always continent of the bowel. Review of care plan dated 10/31/19 revealed Resident #21 had the potential…
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 · D2020-01-02 · tag F0770 — failed to provide lab services — isolatedProvide timely, quality laboratory services/tests to meet the needs of residents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, observation, record review and review of policy the facility failed to ensure lab work was completed per physician orders. This affected two residents (Resident #3 and Resident #16) out of six residents reviewed for hydration (fluid overload) and unnecessary medications. The facility census was 28. Findings included: 1. Review of the medical record for Resident #3 revealed his admission date was 09/12/14 and diagnoses included hypertension, schizoaffective disorder, acute kidney failure, atrial fibrillation, hyperlipidemia, chronic obstructive pulmonary disease, and fluid overload. Review of the care plan dated 09/12/19 revealed Resident #3 had hypertension related to fluid overload and history of alcohol dependence. Interventions included to obtain blood pressure readings and weight per facility policy. Review of the care plan dated 09/12/19 revealed Resident #3 had acute renal failure with fluid overload. Interventions included fluids as ordered, monitor lab reports of electrolytes, report results to physician, and notify physician of a potassium level above…
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 · D2020-01-02 · 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 interview, observation, record review and review of policy the facility failed to ensure proper hand hygiene was completed while changing Resident #19's wound dressings. This affected one resident (Resident #19) out of two residents observed for dressing changes. Findings include: Review of the medical record for Resident #19 revealed an admission date of 06/21/19 and diagnoses that included diabetes, chronic kidney disease, spinal stenosis, and Methicillin Resistant Staph Aureus infection (MRSA) of the left posterior leg wound. Review of a care plan dated 09/03/19 revealed Resident #19 had a potential for and actual pressure injury, surgical wound, rashes, cellulitis, skin tear, and vascular wounds related to difficulty walking, reduced mobility and diabetes. Resident #19 had an abrasion to her left lower lateral leg, a blister to the left lower proximal leg, and an open area to her toe. Interventions included administer treatments as ordered and monitor effectiveness, and to be seen by a wound…
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.
- No harm found · C2024-10-09 · tag F0921 — failed to keep a safe, functional, sanitary building — widespreadMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview and document review, the facility failed to maintain a sanitary environment. This had the potential to effect all 26 residents residing in the facility. Findings include: Review of the document titled State of Ohio Food Inspection Report, dated 09/20/24, revealed there was several spots on the wall in the back storage room, near the mop closet and near the stairway that had dark colored growth on the walls. It was noted the inspector was concerned the water that leaked from the ceiling or walls caused the dark colored growth in the kitchen area. An observation on 10/08/24 at 11:24 A.M. with the Maintenance Director (MD) #330 revealed a black-like substance resembling mold growth on the lower northwest wall leading into the kitchen. Additionally, the facility stored resident service wear on plastic shelves and a freezer was positioned in front of this wall. An Interview conducted on 10/08/24 at 11:26 A.M. with MD #330 confirmed the presence of a black-like substance on the wall leading to the kitchen, as well as behind the plastic shelving 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.
“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.
“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.
- 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
$24,850 in federal fines across 1 penalty.
- $24,850 — penalty dated 2025-05-29
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 AOM HEALTHCARE — 20 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 | 2.7 | +0.3 vs chain |
| Health inspection | 3 of 5 | 2.3 | +0.7 vs chain |
| Staffing | 1 of 5 | 1.6 | -0.6 vs chain |
| Quality measures | 5 of 5 | 4.8 | +0.2 vs chain |
The other 19 homes this chain runs (chain average 2.7★, 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 |
|---|---|---|---|---|
| AMSEL, HINDY | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 10% | since 06/02/2015 |
| GOLDSTEIN, JEFFERY | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | 10% | since 06/02/2015 |
| SHERMAN, ALEXANDER | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | 13% | since 06/02/2015 |
| SHERMAN, TZVI | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 13% | since 06/02/2015 |
| SHERMAN, YEHUDA | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 13% | since 06/02/2015 |
| TRATNER, BATSHEVA | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 10% | since 06/02/2015 |
| ELMERICK, PAULA | Individual | W-2 MANAGING EMPLOYEE | — | since 02/06/2017 |
| ULRICH, AMY | Individual | W-2 MANAGING EMPLOYEE | — | since 08/01/2015 |
| VALIQUETTE, RYAN | Individual | W-2 MANAGING EMPLOYEE | — | since 12/27/2018 |
| SHERMAN, SAMUEL | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 08/01/2015 |
CMS files one row per role, so the 12 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.
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 365902. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-29, 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.