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Vineyards At Concord, The

119 West High Street, Frankfort, OH 45628 · For profit - Corporation · 32 certified beds · (740) 998-4779 Medicare & Medicaid certified

Call the home — (740) 998-4779 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0609, F0610) — most recent Nov 2025Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • no federal fines or payment denials on record
  • lower-than-typical staff turnover (26% vs 45% nationally) — better care continuity
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its independent health-inspection rating is low (2/5)
  • its facility-reported quality-measure rating is low (1/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 1 of 5

Location & what’s nearby

Urgent care / clinic
4439 Ohio 159 #270 · (740) 779-4550 · Call to confirm hours
Pharmacy
2535 Western Ave · (740) 779-6226 · Call to confirm hours
Grocery
617 Frankfort Clarksburg Pike · (740) 998-6200 · Call to confirm hours
Park
Paint Creek Recreational Trail · Typically dawn to dusk
Place of worship

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 1 of 5
Long-stay residentspeople who live here 1 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 held steady at 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.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased34.8%5.3%15.4%worse than state — see note marked double-dagger below the table
Long-stay residents who lose too much weight12.2%6.2%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.2%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection2.9%0.4%2.0%worse than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms11.3%30.1%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury5.7%3.2%3.3%worse
Long-stay residents whose ability to walk worsened31.7%6.1%16.1%worse than state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication29.4%25.5%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%94.5%95.3%typical
Long-stay residents with pressure ulcers1.9%3.4%4.7%better
Long-stay residents with worsening bladder/bowel control21.2%21.4%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table26.7%8.8%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine65.0%75.6%79.4%worse

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

0.15U.S. median 0.31
Therapy hours / resident / day
0.09hours / resident / day
Physical therapy
0.06hours / resident / day
Occupational therapy

Therapy staffing: this home’s payroll records show 0.15 therapist hours per resident per day in 2026Q1 — more than 13% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 5% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot 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 dischargenot 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 dischargenot 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 identified95.0%98.7%Oct 2024–Sep 2025CMS 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 settingnot 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 dischargenot 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot 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 SNFs1.111.02Oct 2022–Sep 2024CMS 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

0.89
RN hours/ resident / day
0.42
LPN hours/ resident / day
1.57
Aide hours/ resident / day
2.88
Total nurse hours/ resident / day
0.70
RN hoursweekends
26.1%
Total nursing turnover
0.0%
RN turnover

How full it usually is: this home is certified for 32 beds and averages 23.9 residents a day — about 75% occupied, or roughly 8 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 2.88 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.89 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.57 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 2.62 hrs/resident/day on weekends vs 2.98 on weekdays — 12% thinner on weekends. RN hours go from 0.97 to 0.70 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 26% is below 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

19
deficiencies at the latest standard inspection (2026-04-28)
2
at the previous standard inspection (2024-11-06)

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.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.

  • Actual harm · Gcited beforedisputed · IDR2026-04-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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 observation, record review, hospital record review, interviews and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 user's manual, the facility failed to ensure adequate fall risk/safety interventions were in place and functioning to prevent falls. Additionally, the facility failed to document and comprehensively investigate falls. Actual harm occurred on 02/11/26 when the facility failed to develop and implement an individualized fall program to prevent falls with injury for Resident #4, who exhibited severe cognitive impairment, had history of falls, and required substantial/maximal assistance with transfers, sustained a fall resulting in a displaced spiral fracture of the right femur requiring surgical repair. This affected two (Residents #4 and #18) of two residents reviewed for falls. The facility census was 27. Findings Include:1. Review of the medical record for Resident #4 revealed an initial admission date of 01/02/26 with the latest readmission date of 02/17/26…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fdisputed · IDR2026-04-28 · tag F0725 — failed to have enough nursing staff — widespread
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and utilization of the staffing tool the facility failed to maintain sufficient staffing to provide for resident care needs. This affected all residents in the facility. The facility census was 27 at the time of survey. Findings include: Observation of meals during survey from 04/13/26 through 04/15/26 revealed meals were being passed late.Observation on 04/13/26 at 3:20 P.M., of Certified Nursing Assistant (CNA) #117 and CNA #127 provide incontinence care for Resident #19 revealed they wheeled her to her room from the dining room where she had been sitting since 8:00 A.M. upon entry to the facility. The resident's pants were pulled down and revealed the resident had a blue brief on and a large liner that was completely saturated with a strong ammonia smelling urine. Interview on 04/13/26 at 3:20 P.M. with CNA #117 revealed the resident was supposed to be toileted every hour and a half. CNA #127 stated, the resident had not been toileted for quite some time. Interview with Director of Nursing on 04/14/26 at 12:05 P.M. reveals that We need help so…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fdisputed · IDR2026-04-28 · tag F0835 — failed to run the facility competently — widespread
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record reviews, interviews and review of job descriptions, the facility failed to be administrated in a manner that uses it's resources effectively and efficiently to ensure resident safety, failed to maintain an activities program directed by a qualified activities professional, failed to maintain sufficient staffing to provide for resident care needs and failed to ensure the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON) and the Registered Dietician (RD) were permitted to work enough hours to effectively complete their job. This deficient practice demonstrated significant breakdowns in administrative oversight and had the potential to affect all 27 residents residing in the facility. Findings include:1. Interview with Director of Nursing (DON) on 04/14/26 at 12:05 P.M. reveals that We need help so bad. We don't have enough staff to take care of our patients. We are understaffed and we need more help, resident care is missed because of it. Utilization of the Survey Staffing Tool completed for 04/07/2026 through 04/13/2026 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-04-28 · tag F0578 — failed to honor advance directives / code status — pattern
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review and interview, the facility failed to establish, maintain and implement written policies and procedures regarding the resident's right to formulate an advance directive. Additionally, the facility failed to develop and implement a comprehensive plan of care for do not resuscitate (DNR) code status. This affected four residents (#3, #4, #15 and #18) of four residents reviewed for advanced directives. The facility census was 27. Findings Include:1. Review of the medical record for Resident #3 revealed an initial admission date of 05/06/24 with the diagnoses including but not limited to schizoaffective disorder, bipolar type, dysphagia, osteoarthritis, Parkinson's disease, irritable bowel syndrome, hypertension, diabetes mellitus, cirrhosis of liver, fatty liver, hyperlipidemia, anemia, diverticulosis of intestine, overactive bladder, esophageal varices and gastro-esophageal reflux disease. Review of the resident's DNR form dated 09/16/25 revealed the resident had elected the code status of do not resuscitate comfort care (DNRCC)-arrest which indicated…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Edisputed · IDR2026-04-28 · tag F0680 — pattern
    Ensure the activities program is directed by a qualified professional.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and observation, the facility failed to maintain an activities program directed by a qualified activities professional. This had the potential to affect all residents with the exception of one (Resident #2). The facility census was 27.Observation throughout the annual survey from 04/13/26 through 04/20/2026 revealed activities of music playing throughout the days in the common area and one activity on 04/15/26 of snack making with residents. No other activities were observed and no activity director was observed in the facility.Interview on 04/13/26 at 2:40 P.M. with Resident #2 stated that she didn't have an issue with the activities because she mostly stays in her room and watches TV and does not wish to attend any activities. Interview on 04/14/26 at 3:15 P.M. with Administrator and Facility Manager #100 confirmed that the facility does not have a current activities director and does not employ anyone with the required qualifications for an activities director. Administrator states we do not have an activities director currently, we haven't had one for a while.…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-04-28 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and interview, the facility failed to ensure medications were stored securely for Resident #18. Additionally, the facility failed to dispose of expired medications on the medication cart. This affected five residents (#2, #4, #7, #15 and #18). The facility census was 27. Findings Include:1. Review of the medical record for Resident #18 revealed an initial admission date of 02/19/26 with the diagnoses including but not limited to atrial fibrillation, allergic rhinitis, hyperlipidemia, osteoarthritis, constipation, atherosclerotic heart disease, anxiety disorder, hypertension, chronic pain syndrome, diabetes mellitus, chronic kidney disease, chronic obstructive pulmonary disease (COPD), gastro-esophageal reflux disease and obstructive sleep apnea. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. Review of the resident's monthly physician orders for April 2026 identified orders dated…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-04-28 · tag F0800 — pattern
    Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and staff interviews the facility failed to follow diet orders when dietary staff served mechanical textured meat to residents on a regular diet during lunch meal. This had the potential to affect 18 ( #1, #2, #4, #6, #7, # 8, #11, #13, #14, #18, #21, #22, #23, #24, #25, #26, #27, and #29) who receive a regular diet. The facility census was 27. Observation on 04/15/26 at 12:15 P.M. with [NAME] #118 revealed the lunch meal was pork and sauerkraut, mashed potatoes and bread pudding. The pork and sauerkraut were made into mechanical texture and served to residents who are on a regular diet. Associate #118 confirmed pork was mechanical texture and she does this so residents receive the same looking meat and to reduce choking hazard. Pureed pork and sauerkraut was made with milk. Associate #118 confirmed she used milk to puree pork and sauerkraut because it adds calories and nutrients. Review of the medical records revealed 18 ( #1, #2, #4, #6, #7, # 8, #11, #13, #14, #18, #21, #22, #23, #24, #25, #26, #27, and #29) residents received a regular diet. Interview 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-04-28 · tag F0802 — failed to prepare enough nourishing food — pattern
    Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and staff interviews the facility failed to prepare and deliver meals timely according to dining schedule. This had the potential to affect affect 26 residents receiving food in the facility. The facility identified one resident (#5) who received nothing by mouth (NPO). The facility census was 27. Interview on 04/13/26 at 8:30 A.M. with [NAME] #118 regarding meal times-breakfast is served at 7:45/8:00 A.M., lunch is served at 11:45/12:00 P.M. and dinner at 4:30/5:30 P.M. Dining staff consist of cook and occasionally a hospitality aide. Observation on 04/13/26 at 12:21 P.M. lunch has not started to be served to 11 residents sitting in dining room. Hospitality aide present to assist. Observation on 4/14/26 at 9:00 A.M. breakfast starting to be served to residents in dining room. Observation on 4/15/26 at 8:50 A.M. breakfast was not being served yet. Interview on 04/15/26 at 8:55 A.M. with [NAME] #118 confirmed waiting on hall trays to be served to residents before serving dining room. Dining room had eight residents (Resident #4, Resident #7, Resident #11,…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-04-28 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and staff interviews the facility failed to follow the menu, complete substitution log as needed and prepare meal with appropriate diet order. This had the potential to affect 26 residents receiving food in the facility. The facility identified one resident (#5) who received nothing by mouth (NPO). The facility census is 27. Review of the menu revealed lunch for 04/15/26 consisted of pork and sauerkraut, mashed potatoes, and pumpkin bread pudding. Observation on 04/15/26 at 12:15 P.M. with [NAME] #118 revealed lunch meal was being prepared that included pork and sauerkraut, mashed potatoes ( instead of scalloped potatoes per menu) and apple bread pudding ( instead of pumpkin bread pudding per menu). The pork and sauerkraut were made into mechanical texture and was prepared for residents who are on a regular diet. Interview on 04/15/26 at 12:30 P.M. with [NAME] #118 confirmed the pork was mechanical texture and she does this so residents receive the same looking meat and to reduce choking hazard. [NAME] #118 also verified she did not follow a menu…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-04-28 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure 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 and interviews the facility failed to store food appropriately and ensure a sanitary environment. This had the potential to affect 26 residents who receive food from the kitchen. The facility had one resident (#5) who received nothing by mouth (NPO). The facility census was 27.Observation on 04/13/26 at 8:30 A.M. with [NAME] #118 during walk through revealed in the dry storage areas of concern included scoop in sugar container, 50-lb oats bag not sealed or dated and was located on the floor, no dates on beans, sugar and rice containers. Freezer areas of concern included no dates on bags of green beans, cauliflower, broccoli, carrots, tater tots or hashbrowns. Refrigerator areas of concern included pepperoni dated 01/26/26, deli cheese with no date, veggie and fruit tray with no date, and mustard with no label or date. Resident food brought in by family or visitors included cubed cheese no date, grapes no date or label, cuties no date, red seedless grapes no date, and a styrofoam box of food with no date. Drink containers of juice, house shake, tea and lemonade…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-28 · tag F0557 — isolated
    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
    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, policy review and staff and resident interviews, the facility failed to ensure dignity and respect were shown to resident who needed assistance to eat. This affected one (#16) of one resident reviewed for assistance with eating. The facility census was 27.Medical record review for Resident #16 was admitted on [DATE]. Medical diagnoses included Huntington's disease, anxiety and depression.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16's Brief Interview for Mental Status (BIMS) was 09 out of 15 indicating resident has moderate cognitive impairment. His functional status for eating was maximum assistance. Observation of the dining room on 04/13/26 at 12:00 P.M. revealed Resident #16 was among 11 unidentified residents sitting at the dining table waiting for lunch. Observation of the dining room on 04/13/26 at 12:26 P.M. lunch meal was served to these unidentified 11 residents and not to Resident #16, and they started eating.…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 19 citations
  • Potential for harm · D2026-04-28 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately 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 medical record review and interview, the facility failed to notify the physician of significant weight loss. This affected two residents (#4 and #15) of three residents reviewed for nutrition. The facility census was 27. Findings Include:1. Review of the medical record for Resident #4 revealed an initial admission date of 01/02/26 with the latest readmission date of 02/17/26 with the diagnoses including but not limited to displaced spiral fracture of shaft of right femur, moderate protein calorie malnutrition, neuromuscular dysfunction of bladder, encounter for palliative care, anemia, osteoporosis, diabetes mellitus, insomnia, hypertensive heart disease, hyperlipidemia, delusional disorder, hypertension, history of falling, history of nontraumatic fracture. Review of the resident's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. The resident required supervision or touching assistance with eating. The resident's weight was 103…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-28 · tag F0628 — isolated
    Provide 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 medical record review, interview and facility policy review, the facility failed to provide a written bed hold notice upon transfer to an acute care setting. Additionally, the facility failed to provide a comprehensive discharge summary upon a planned discharge from the facility. This affected two residents (#10 and #20) of four residents reviewed discharge. The facility census was 27. Findings Include:1. Review of the medical record for Resident #10 revealed an initial admission date of 03/24/25 with the last readmission date of 02/12/26 with the diagnoses including but not limited to anxiety disorder, heart failure, osteoarthritis, atrial fibrillation, dementia, with behavioral disturbances, chronic pain, Alzheimer's disease, polycythemia vera, polyneuropathy, peripheral venous insufficiency, depression, hypertensive heart disease, hypertension, gastro-esophageal reflux disease, insomnia and peripheral vascular disease. The resident was discharged to an in-patient psychiatric hospital on [DATE].…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-28 · tag F0636 — isolated
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    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 resident record review, interview and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 user's manual the facility failed to ensure the comprehensive Minimum Data Set (MDS) assessment was completed within the first 14 days. This affected one resident (#20) of 15 sampled residents. The facility census was 27. Findings Include: 1. Review of the medical record for Resident #20 revealed an initial admission date 03/27/26 with the diagnoses of including but not limited to pyothorax, anemia, elevated white blood cell count, presence of heart valve replacement, presence of prosthetic heart valve, osteoporosis, nicotine dependence, convulsions, hyperlipidemia, depression, pleural effusion, hypothyroidism, mood disorder, atrial fibrillation and generalized anxiety disorder. Review of the resident's admission comprehensive MDS assessment dated [DATE] revealed the assessment was still in progress more than 14 days following the resident's admission. On 04/14/26 at 10:51 A.M., an…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-28 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and interview, the facility failed to develop a comprehensive plan of care to address resident needs and conditions. This affected two residents (#4 and #18) of 15 sampled residents. The facility census was 27. Findings Include:1. Review of the medical record for Resident #4 revealed an initial admission date of 01/02/26 with the latest readmission date of 02/17/26 with the diagnoses including but not limited to displaced spiral fracture of shaft of right femur, moderate protein calorie malnutrition, neuromuscular dysfunction of bladder, encounter for palliative care, anemia, osteoporosis, diabetes mellitus, insomnia, hypertensive heart disease, hyperlipidemia, delusional disorder, hypertension, history of falling, history of nontraumatic fracture. Review of the resident's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. The assessment indicated the resident was using a bed alarm daily. 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-28 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and interview, the facility failed to provide residents who were dependent on staff for nail care. This affected two residents (#15 and #19) of five residents reviewed for activities of daily living (ADL). The facility census was 27. Findings Include:1. Review of the medical record for Resident #15 revealed an initial admission date of 04/20/25 with the latest readmission of 05/25/25 with the diagnoses including but not limited to neuropathy, peripheral vascular disease, hypertensive heart disease, vascular dementia, major depressive disorder, cerebral infarction, dementia, hypertension, gout, insomnia and anxiety disorder. Review of the plan of care not dated revealed the resident had an activity of daily living (ADL) self-care performance deficit related to cerebrovascular accident, restlessness and dementia. Interventions check nail length, trim and clean on bath day and as necessary. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE]…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-28 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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 medical record review and interview, the facility failed to comprehensively assess skin impairment upon discovery and subsequently weekly assessment thereafter. This affected one resident (#18) of one resident reviewed for skin impairment. The facility census was 27. Findings Include:Review of the medical record for Resident #18 revealed an initial admission date of 02/19/26 with the diagnoses including but not limited to atrial fibrillation, allergic rhinitis, hyperlipidemia, osteoarthritis, constipation, atherosclerotic heart disease, anxiety disorder, hypertension, chronic pain syndrome, diabetes mellitus, chronic kidney disease, chronic obstructive pulmonary disease (COPD), gastro-esophageal reflux disease and obstructive sleep apnea. Review of the medical record revealed no documented evidence a comprehensive admission assessment was completed on admission to the facility. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-28 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide 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 observation, medical record review and interview, the facility failed to provide routine incontinence care. This affected two residents (#15 and #19) of three residents reviewed for bowel and bladder. The facility census was 27. Findings Include:1.Review of the medical record for Resident #15 revealed an initial admission date of 04/20/25 with the latest readmission of 05/25/25 with the diagnoses including but not limited to neuropathy, peripheral vascular disease, hypertensive heart disease, vascular dementia, major depressive disorder, cerebral infarction, dementia, hypertension, gout, insomnia and anxiety disorder. Review of the plan of care not dated revealed the resident had bladder incontinence related to dementia. Interventions included notify nursing if incontinent during activities, encourage fluids during the day to promote promoted voiding responses, establish voiding patterns, monitor and document intake and output as per facility policy, monitor fluid intake to determine if natural…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-28 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, hospital record review and policy review, the facility failed to provide a comprehensive, resident centered plan of care to prevent, timely identify, and treat weight loss for residents. Additionally, the facility failed to ensure weights were obtained, documented, and monitored for weight loss, failed to ensure meal intake percentages were documented at every meal, and failed to ensure supplements were provided per order and failed to follow the recipe for supplements to ensure residents received the proper nutritional support. This affected two (Residents #4 and #8 ) of three residents reviewed for nutrition/weight loss. The facility census was 27.Findings include:1.Review of Resident #8's medical record revealed an admission date of 12/23/25 with diagnoses including Alzheimer's disease, general anxiety, and abnormal weight loss. Review of a physician's order dated 12/23/25 revealed Resident #8 received a regular diet with thin liquids. Review of Resident #8'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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-28 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide 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 and interview, the facility failed to ensure continuous positive airway pressure (CPAP) had physician ordered settings, cleansing and was stored in a manner to prevent potential infection. This affected one resident (#18) of one resident reviewed for respiratory care. The facility census was 27. Findings Include:Review of the medical record for Resident #18 revealed an initial admission date of 02/19/26 with the diagnoses including but not limited to atrial fibrillation, allergic rhinitis, hyperlipidemia, osteoarthritis, constipation, atherosclerotic heart disease, anxiety disorder, hypertension, chronic pain syndrome, diabetes mellitus, chronic kidney disease, chronic obstructive pulmonary disease (COPD), gastro-esophageal reflux disease and obstructive sleep apnea. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. Review of the resident's monthly physician orders for April 2026…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-28 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    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 interview, the facility failed to ensure medications were available for administration. This affected one resident (#18) of two residents observed for medication administration. The facility census was 27. Findings Include:Review of the medical record for Resident #18 revealed an initial admission date of 02/19/26 with the diagnoses including but not limited to atrial fibrillation, allergic rhinitis, hyperlipidemia, osteoarthritis, constipation, atherosclerotic heart disease, anxiety disorder, hypertension, chronic pain syndrome, diabetes mellitus, chronic kidney disease, chronic obstructive pulmonary disease (COPD), gastro-esophageal reflux disease and obstructive sleep apnea. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. Review of the resident's monthly physician orders for April 2026 identified orders dated 02/20/26 B-Complex with Biotin and Folic Acid one tablet by mouth…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-28 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and interview, the facility failed to ensure a medication error rate of less than five percent. Twenty-five opportunities for error were observed with three medication errors made resulting in a 12 percent error rate. This affected one resident (#18) of two residents observed during the medication pass. The facility census was 27. Findings Include:Review of the resident's monthly physician orders for [DATE] identified orders dated [DATE] Omeprazole 40 milligrams (mg) by mouth daily and [DATE] B-Complex with Biotin and Folic Acid one tablet by mouth daily, Vitamin E 400 capsule by mouth daily. On [DATE] at 9:11 A.M., observation of Licensed Practical Nurse (LPN) #102 prepare the resident's morning medication revealed she placed two Omeprazole 20 mg capsules from a stock bottle with the expiration date of 03/26 in a clear plastic cup. Further observation revealed the LPN #102 had no Complex with Biotin and Folic Acid or Vitamin E 400 capsule on hand to administer to 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-28 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, interview and facility policy review revealed the facility failed to maintain infection control practices to prevent the potential spread of infection. This affected two residents (#5 and #20) of 15 residents reviewed for infection control. The facility census was 27.Findings Include: 1.Review of the medical record revealed Resident #5, specified, was admitted to the facility on [DATE]. Diagnoses included metabolic encephalopathy, severe dementia with anxiety, Alzheimer's disease, essential hypertension, and dysphagia. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition with hallucinations and delusions, rejected care, and did not wander. Resident #5 is dependent for all care and has a gastric feeding tube placed. Observation of gastric tube feed for Resident #5 on 04/14/2026 at 11:59 A.M. revealed that no personal protective equipment (PPE) was available outside of or inside the room 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-11-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interviews, and facility policy review, this facility failed to ensure resident falls were reported, investigated and fall care plans were in place. This affected four (Resident #106, #56, #70, and #78) of the four resident reviewed for falls. The facility census was 19. Findings include: 1. Review of the medical record for Resident #106 revealed an admission date of 08/14/2025 and a discharge date of 10/14/2025. Diagnoses included Alzheimer's disease, muscle weakness, anxiety, and adult failure to thrive. Review of the plan of care dated 08/15/2025 and revised 10/15/2025 for Resident #106 revealed this resident was at risk for falls. Interventions included to anticipate and meet residents needs, ensure a safe environment and floors are free from spills, and clutter. Review of the Fall Risk assessment dated [DATE] revealed a score of 20 indicating Resident #106 was at a high risk for falls. Review of the progress note dated 08/15/2025 at 12:43 A.M. created by Licensed…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-19 · tag F0609 — failed to report abuse allegations — isolated
    Timely 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 medical record review, staff interview, and facility policy review, this facility failed to report resident to resident abuse as well as injury of unknown origin to the appropriate agencies. This affected one (Resident #106) of the four residents reviewed for abuse and injuries. The facility census was 19. Findings include:Review of the medical record for Resident #106 revealed an admission date of 08/14/2025 and a discharge date of 10/14/2025. Diagnoses included Alzheimer's disease, muscle weakness, anxiety, and adult failure to thrive. Review of the plan of care dated 08/15/2025 and revised 10/15/2025 for Resident #106 revealed this resident was at risk for falls. Interventions included to anticipate and meet residents needs, ensure a safe environment and floors are from spills, and clutter. Review of Resident #106's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15 indicating an moderately impaired cognition for…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-19 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond 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 medical record review, staff interview and facility policy review, this facility failed to ensure all injuries of unknown origin was investigated. This affected one (Resident #106) of the four residents reviewed for injuries. The facility census was 19. Findings include:Review of the medical record for Resident #106 revealed an admission date of 08/14/2025 and a discharge date of 10/14/2025. Diagnoses included Alzheimer's disease, muscle weakness, anxiety, and adult failure to thrive. Review of the plan of care dated 08/15/2025 and revised 10/15/2025 for Resident #106 revealed this resident was at risk for falls. Interventions included to anticipate and meet residents needs, ensure a safe environment and floors are from spills, and clutter. Review of Resident #106's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15 indicating an moderately impaired cognition for daily decision making abilities. Resident #106 was noted…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-06 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 record reviews and staff interview, the facility failed to ensure a significant change Preadmission Screening and Resident Review (PASARR) was completed following the addition of a new mental health diagnosis. This affected two (#3 and #7) of the four residents reviewed for PASARR during the annual survey. The facility census was 21. Findings include: 1. Review of the medical record for Resident #3 revealed an admission date of 06/11/20, with diagnoses including: hypertension, dementia, insomnia, chronic respiratory failure, unspecified psychosis, basal cell carcinoma, macular degeneration, peripheral vascular disease, hallucinations, peripheral vascular disease, chronic embolism and thrombosis, insomnia, schizophrenia, atherosclerosis, and delusional disorders. A diagnosis of unspecified psychosis was added on 07/21/22. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #3 had severely impaired cognition . Review of completed PASSAR documents revealed the facility did not…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-06 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure a stop date for as needed psychotropic medications. This affected two (#14 and #15) of the five residents reviewed for unnecessary medications during the annual survey. The facility census was 21. Findings include: 1. Record review for Resident #14 revealed the resident was admitted to the facility on [DATE] and had diagnoses including anxiety disorder, allergic rhinitis, and urge incontinence. Review of the 5-Day Minimum Data Set (MDS) assessment, dated 10/16/24, revealed the resident was assessed to have intact cognition. Review of the active physicians order, dated 10/15/24, revealed an order for 25 milligrams (mg) of Hydroxyzine (an antianxiety medication) to be administered every six hours as needed for anxiety. The order did not contain a stop date. Review of the active physicians order, dated 10/17/24, revealed an order for one mg of Xanax (an antianxiety medication) to be administered every 12 hours as needed for anxiety. The order…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-04-18 · tag F0638 — pattern
    Assure that each resident’s assessment is updated at least once every 3 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of the online Resident Assessment Instrument (RAI) manual, the facility failed to complete required Minimum Data Set (MDS) assessments. This affected 10 (#1, #6, #9, #10, #12, #116, #117, #118, #164, and #166) of 17 residents reviewed for completed MDS assessments. The facility census was 23. Findings include: 1. Record review for Resident #1 revealed no MDS assessments had been completed for the resident since the annual MDS assessment dated [DATE]. 2. Record review for Resident #6 revealed no MDS assessments had been completed for the resident since the quarterly MDS assessment dated [DATE]. 3. Record review for Resident #9 revealed no MDS assessments had been completed for the resident since the quarterly MDS assessment dated [DATE]. 4. Record review for Resident #10 revealed no MDS assessments had been completed for the resident since the quarterly MDS assessment dated [DATE]. 5. Record review for Resident #12 revealed no MDS assessments had been…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-04-18 · tag F0640 — pattern
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of the online Resident Assessment Instrument (RAI) manual, the facility failed to timely complete and submit the Minimum Data Set (MDS) assessments. This affected eight (#1, #3, #4, #13, #116, #117, #164, and #166) of 17 residents reviewed for completed and submitted MDS assessments. The facility census was 23. Findings include: 1. Record review for Resident #1 revealed the quarterly MDS assessment, dated 12/10/21, was in in progress and had not been submitted. 2. Record review for Resident #3 revealed the quarterly MDS assessment, dated 02/06/22, was in progress and had not been submitted. 3. Record review for Resident #4 revealed the annual MDS assessment, dated 02/02/22, was in progress and had not been submitted 4. Record review for Resident #13 revealed the admission MDS assessment, dated 03/28/22, was in progress and had not been submitted. 5. Record review for Resident #116 revealed the entry MDS assessment, dated 12/17/21, and the admission 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleShareSince
BURKE, RACHELIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF25%since 02/16/2020
HICKS, JOSHUAIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF25%since 01/07/2009
SMITH, ROBBIEIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; TRUSTEE OF THE SNF; ADP OF THE SNF25%since 01/07/2009
WARNER, TIRZAHIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL25%since 02/16/2020
DEER FIELD REALTY HOLDINGS, LLCOrganizationDIRECT OWNERSHIP INTEREST; INDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 01/07/2009
HICKS FAMILY TRUSTOrganizationOPERATIONAL/MANAGERIAL CONTROL; TRUSTEE OF THE SNF; ADP OF THE SNFsince 02/16/2020
EXTENDED CARE SPECIALISTS, INCOrganizationADP OF THE SNFsince 07/03/2025
JUSCHKA, DIRKIndividualADP OF THE SNFsince 01/01/2012

CMS files one row per role, so the 23 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.

3 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.

$2.4M
Net patient revenuemost recent cost report
-9.2%
Operating marginrevenue minus expenses
$300K
Related-party expense11% of expenses
Who pays — share of resident-days
Medicaid 67%Medicare 6%Other / private 26%

This home reported $300K paid to related parties — landlords or management companies under common ownership — equal to about 11% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$280per resident / day
operating cost
$8,515per month
≈ monthly operating cost
$256per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in Ohio
$9,186/mo
Nursing home (semi-private)
$10,389/mo
Nursing home (private)
$6,103/mo
Assisted living

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 366360. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-28, 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.

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