SNF-The Villa At Marymount

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

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.

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.

59.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 263 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 46.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 90 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.53 therapist hours per resident per day in 2026Q1 — more than 84% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 10% 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.

Staffing

How full it usually is: this home is certified for 130 beds and averages 105.0 residents a day — about 81% occupied, or roughly 25 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 4.03 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.46 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.17 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 3.39 hrs/resident/day on weekends vs 4.29 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 0.56 to 0.22 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 63% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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.

27 citations, most serious first. The 14 most serious are shown; the remaining 13 are one tap away and print in full.

• Immediate jeopardy · Jcited before2023-11-08 · 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 medical record review, staff interview, power of attorney (POA) interview, resident interview, review of a Self -Reported Incident (SRI) and investigation, review of facility sign out sheets, and review of the facility policy for signing residents out, the facility failed to provide supervision and follow the facility policy for a resident signing out for a leave of absence (LOA) to ensure the whereabouts for one resident (Resident #87) who had left the facility after reporting she was leaving on a LOA. This resulted in Immediate Jeopardy and the potential for serious harm, injury or death, on 10/24/23 at approximately 4:30 P.M. when Resident #87, who had mild dementia and required supervision and assistance for activities of daily living, informed staff she was leaving with a friend for an LOA. The staff were unaware of the sign out procedure and did not have the resident sign out. The resident did not return to the facility and facility staff did not recognize she had not returned for over 42 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-03-13 · 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 record review, hospital record review, and interview, the facility failed to ensure Resident #16 was safely assisted with activities of daily living to prevent a fall with major injury. Actual harm occurred on 02/06/25 when Resident #16, who was comprehensively assessed and ordered to need two staff members to assist when giving personal care, received incontinence care by only one staff member, resulting in a fall, hospitalization, and fractured hip. This affected one resident (#16) of five residents reviewed for falls. The total census was 110. Findings include: Review of Resident #16's medical record revealed the resident was admitted to the facility on [DATE] and had diagnoses including multiple sclerosis, disorder of bone density, and obesity. A plan of care dated 10/11/24 revealed the resident required two people to be present when providing care. Record review revealed the resident had an active physician order dated 10/13/24 for two people to be present when providing care. Resident #16'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
• Actual harm · Gcited before2024-02-20 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed medical record review, policy review and interview, the facility failed to provide preventive care consistent with professional standards of practice to promote healing of a pressure ulcer wound for Resident #98. This affected one (Resident #98) of three residents reviewed for pressure ulcers. The census was 97. Actual harm occurred for Resident #98 when a Stage I pressure ulcer (intact skin with a localized area of non-blanchable erythema/redness) to the resident's coccyx, which was identified on 01/10/24, was noted to have deteriorated to a deep tissue injury (intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue) on 01/23/24 after the facility did not implement pressure-reducing interventions, did not consistently implement physician wound care orders, did not explore reasoning as to why Resident #98 refused a dressing change, and did not educate Resident #98 on the importance of dressing changes after…

  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
• Actual harm · Gcited before2023-11-08 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, facility policy review, staff interview, and resident interview, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to prevent the development of a pressure ulcer for Resident #33. Actual Harm occurred on 10/09/23 when Resident #33, who required extensive assistance from staff for bed mobility and activity of daily living care including turning and repositioning, developed an unstageable pressure ulcer to the left buttocks without being provided adequate pressure relief. Additionally, the resident was left soiled with stool that was in contact with the pressure ulcer wound. This affected one resident (#33) of three residents reviewed for pressure ulcers. Findings include: Record review revealed Resident #33 was admitted to the facility on [DATE] from the hospital with diagnoses including COVID-19 infection, diabetes mellitus with a right below the knee amputation, pulmonary embolism, high blood pressure,…

  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 · Ddisputed · IDR2026-06-11 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
  Honor 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 interviews and observation the facility failed to ensure preventive maintenance measures were in place to ensure Heating, Ventilation, and Air Conditioning (HVAC) system functioned properly to keep the air temperature in proper range. This had the potential to affect all twenty-two (22) Residents residing on the Care Hall. Facility census was 95. Findings include: Review of the temperature logs for 06/09/26 at 12:30 P.M., taken by Maintenance Director #312 revealed the following temperatures, Resident #95's room temperature was 90 degrees Fahrenheit (F), Resident #70's room was 90.1 F degrees, by the chapel the temperature was 85.2 Fdegrees, and Resident #13's room was 89.8 F degrees.Interview on 06/10/26 at 2:33 P.M. with Licensed Practical Nurse (LPN) #285 confirmed the Air Conditioning unit had not been working for a couple of weeks or more.Review of the temperatures taken by Maintenance Director #312, taken with his thermometer, on 06/10/26 from 2:19 P.M. to 2:29 P.M. of the following rooms 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-03-13 · tag F0804 — failed to serve food at safe, palatable temperature — widespread
  Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility did not ensure food was served at a palatable temperature. This had the potential to affect 107 residents who received food from nutrition services. The facility census was 110. Findings include: Observation was conducted on 03/11/25 at 11:40 A.M. during meal service. The food temperatures were taken with a calibrated thermometer as follows: roasted chicken 185 degrees Fahrenheit ( F), green beans 165 degrees F, twice baked potato 165 degrees F, and entrée substitute was 185 degrees F. The test tray was placed on the [NAME] Unit hall cart at 12:40 P.M. where nurse staff passed the [NAME] Unit trays. At 12:56 P.M a test tray was taken from the [NAME] Unit food cart, after the last tray was passed. The Dietary Manager #347 proceeded to take the food temperatures with the facility digital thermometer confirming the temperatures. The test tray temperatures were as followed: roasted chicken 112 degrees F, green beans 107 degrees F, twice baked potato 121 degrees F,…

  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 · Fcited before2025-03-13 · tag F0812 — failed to store, cook, and serve food safely — widespread
  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, staff interview and facility policy review the facility failed to ensure the kitchen was clean and sanitary. This had the potential to affect all 107 residents receiving food from the kitchen as three residents (Resident #30, #102, and #167) received no food by mouth. The facility census was 110. Findings include: Observation during initial kitchen tour on 03/10/25 between 08:36 A.M. and 9:30 A.M. with Dietary Manager #347 revealed the following concerns: • Hand drying paper towels were not available at the employee handwashing station. • Cooler doors were not clean with food residue stuck on the door handles. • The tray line cooler contained opened American cheese that was not dated, along with food debris throughout the cooler. An expired one half gallon on milk dated 03/08/25, expired lime juice dated 11/09/24, and no expiration date was on the gallon size mayonnaise container. • The griddle had multiple food items charred on it. Food was charred on the stove top with food debris under the stove. The range broiler window was coated in grease and food 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-03-13 · tag F0868 — widespread
  Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
  What the surveyor found here — the official record, unedited, may be distressing

  Based on record review and interview the facility failed to have quarterly Quality Assurance meetings. This had the potential to affect all residents. The census was 110. Findings Include: Review of the Quality Assurance (QA) meeting minutes revealed minutes starting in October 2024 to current date. Interview on 03/13/25 at 2:22 P.M. with the Administrator revealed he developed the QA program when he started at the facility in October 2024. He stated there were no prior meeting minutes for review.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-03-13 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
  Develop and implement policies and procedures for flu and pneumonia vaccinations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents and/or representatives were provided education regarding the benefits and potential side affects of the influenza and pneumococcal immunizations and the resident's records reflected the consent or refusal of the vaccines and the education provided. This finding affected four (Residents #80, #166, #215 and #217) of five residents reviewed for immunizations. Findings include: 1. Review of Resident #80's medical record revealed the resident was admitted on [DATE] with diagnoses including acute kidney failure, diabetes and muscle weakness. Review of Resident #80's immunization section of the medical record revealed the resident refused the influenza and pneumococcal vaccines. There was no evidence the resident received a Vaccine Conset Form with education regarding the vaccine. Interview on 03/11/25 at 3:08 P.M. with Registered Nurse (RN) Infection Preventionist (IP) #338 confirmed these findings and revealed she was new to the IP role as…

  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 · D2025-03-13 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interviews and review of facility policy, the facility failed to ensure staff treated residents with respect and dignity. This affected one resident (Resident #81) of four residents reviewed for dignity. The facility census was 110. Findings include: Record review revealed Resident #81 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, other nontraumatic intracerebral hemorrhage, muscle weakness, adjustment disorder with mixed anxiety and depressed mood. Pertinent medication orders included (Remeron Oral Tablet (antidepressant) 15 milligrams (MG) once daily for depression. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 13 of 15, indicating the resident was cognitively intact. Resident #81 was usually understood, usually understands. Resident #81 required set up with 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
• Potential for harm · Dcited before2025-03-13 · 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 observations, interviews and record review, the facility failed to ensure residents received adequate timely assistance with eating and oral hygiene. This affected two residents (Resident #16 and Resident #223) of three residents investigated for activities of daily living (ADL) care. The facility census was 110. Findings include: Resident #16 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Multiple Sclerosis, fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing, and other specified disorders of bone density and structure. Review of Resident #16's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had mild or no cognitive impairment and required substantial/maximal assistance for hygiene care. Review of Resident #16's care plan dated 02/11/25 revealed the resident had an ADL self-care performance deficit due to impaired balance, had Multiple Sclerosis, and bilateral lower extremities weakness. Goals…

  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 · D2025-03-13 · 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 record review, and interview the facility failed to monitor and implement nutrition oral supplements as recommended by the registered dietitian and implement weekly weights as ordered by the physician. This affected one resident ( Resident # 166) of three residents reviewed for nutrition. The facility census was 110. Findings include: Review of Resident's #166 medical record revealed an admission date of 01/08/25 with diagnoses included pressure ulcer of sacral region stage four, type two diabetes, neuromuscular dysfunction of bladder, urinary tract infection, major depressive disorder, sepsis, anemia, protein calorie malnutrition, gastro-esophageal reflux, dementia, fracture of right lower leg, fracture of tibia. Review of Resident #166 admission Minimum Data Set ( MDS) 3.0 assessment dated [DATE] revealed cognition was moderately impaired. Resident #166 had no rejection of care. Set up clean up assistance was needed for eating, and personal hygiene. Moderate assistance was needed to roll left 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-03-13 · tag F0757 — failed to avoid unnecessary drugs — isolated
  Ensure each resident’s drug regimen must be free from unnecessary 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 record review and interview, the facility failed to ensure Resident #216's antibiotic medication was discontinued timely following notification of a negative urine culture. This finding affected one (Resident #216) of six residents reviewed for medication administration. Findings include: Review of Resident #216's medical record revealed the resident was admitted on [DATE] with diagnoses including adult T-Cell lymphoma not having achieved remission, essential hypertension and hyperlipidemia. Review of Resident #216's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #216's physician orders revealed an order dated 02/24/25 to give Cephalexin capsule 500 milligrams (mg) one capsule by mouth three times a day for an infection until the sensitivity was available. Review of Resident #216's medication administration records (MARS) from 03/01/25 to 03/11/25 revealed the Cephalexin antibiotic was due at 6:00 A.M., 2:00 P.M. and 10:00 P.M. 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-03-13 · 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, record review and interview, the facility failed to ensure the glucometer blood glucose testing (BGT) machine was appropriately sanitized and disinfected to prevent the potential of cross contamination of blood borne pathogens. This finding affected two residents (Residents #80 and #166) of three residents (Residents #80, #166 and #209) who receive medications from the Hall One medication administration cart. Findings include: 1. Review of Resident #209's medical record revealed the resident was admitted on [DATE] with diagnoses including type two diabetes, difficulty in walking and muscle weakness. Review of Resident #209's physician orders revealed an order dated 02/16/25 for BGT before meals and at bedtime for hypo/hyerglycemia and diabetes. Review of Resident #209's medication administration records (MARS) from 03/01/25 to 03/10/25 revealed the BGT's were due at 6:00 A.M., 11:00 A.M., 4:00 P.M. and 9:00 P.M. The documentation confirmed Licensed Practical Nurse (LPN) #650 obtained a BGT…

  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

“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.

Fines & penalties

$83,603 in federal fines across 2 penalties. 1 Medicare payment denial on record.

• $29,601 — penalty dated 2025-03-13
• $54,002 — penalty dated 2023-11-08
• Medicare payment denial — starting 2024-03-19 for 5 days

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.

Who owns this facility

CMS files one row per role, so the 21 rows in the source record cover these 15 parties — each is shown once here with every role it holds. Nothing is omitted.

8 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

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