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Geneva Center For Rehabilitation And Nursing

1140 South Broadway, Geneva, OH 44041 · For profit - Limited Liability company · 80 certified beds · (440) 466-5809 Medicare & Medicaid certified

Call the home — (440) 466-5809 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0606) — cited Jun 2024Resident-funds citation (F0567)1 actual-harm citation1 Medicare payment denial
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0606), cited Jun 2024
  • it has a citation for mishandling residents’ money or property (F0567)
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (1/5)
  • nursing-staff turnover (67%) runs well above the national median (45%)

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

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

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
870 W Main St Ste 102 · (440) 205-5870 · Call to confirm hours
Pharmacy
Pharmacy0.3 mi
755 South Broadway Avenue
Grocery
84 S Ridge Rd E · (440) 466-0626 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
1007 S Broadway · (440) 466-7689

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 3 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 2 to 1 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 rating1★
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 increased1.6%5.3%15.4%better than state — see note marked double-dagger below the table
Long-stay residents who lose too much weight12.1%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 infection1.0%0.4%2.0%worse than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms23.0%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 injury7.7%3.2%3.3%worse
Long-stay residents whose ability to walk worsened3.2%6.1%16.1%better than state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication12.6%25.5%18.9%better
Long-stay residents given the seasonal flu vaccine93.5%94.5%95.3%typical
Long-stay residents with pressure ulcers2.5%3.4%4.7%better
Long-stay residents with worsening bladder/bowel control25.3%21.4%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table4.6%8.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.9%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine84.6%75.6%79.4%typical
Short-stay residents rehospitalized after admission33.4%24.9%22.6%worse
Short-stay residents with an outpatient ER visit13.6%12.9%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.281.731.67better
Long-stay outpatient ER visits per 1,000 resident days4.051.801.80worse

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.

55.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 88 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

55.8%U.S. median 51.5%
Got home and stayed home
11.7%U.S. median 10.7%
Went back to hospital
82.3%U.S. median 56.6%
Met the expected recovery
0.29U.S. median 0.31
Therapy hours / resident / day
0.12hours / resident / day
Physical therapy
0.14hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 82.3% 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 34 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 0.29 therapist hours per resident per day in 2026Q1 — more than 44% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 19% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF55.8%CMS range 44.3–65.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.7%CMS range 8.9–15.810.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge82.3%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge82.3%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge47.1%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%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 discharge95.8%98.7%Oct 2024–Sep 2025CMS makes no comparison for this 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 worsened4.1%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 hospitalization7.4%CMS range 4.5–11.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.101.02Oct 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

0.55
RN hours/ resident / day
0.74
LPN hours/ resident / day
1.76
Aide hours/ resident / day
3.06
Total nurse hours/ resident / day
0.32
RN hoursweekends
66.7%
Total nursing turnover
58.3%
RN turnover

How full it usually is: this home is certified for 80 beds and averages 68.7 residents a day — about 86% occupied, or roughly 11 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.06 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.550 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.76 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 2.76 hrs/resident/day on weekends vs 3.18 on weekdays — 13% thinner on weekends. RN hours go from 0.64 to 0.32 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 67% is well above the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

2
deficiencies at the latest standard inspection (2026-04-16)
14
at the previous standard inspection (2024-06-03)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

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.

25 citations, most serious first. The 11 most serious are shown; the remaining 14 are one tap away and print in full.

  • Actual harm · Gcited before2024-06-03 · 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 and interview the facility failed to provide comprehensive, individualized and necessary pressure ulcer assessment and care for Resident #56. This affected one resident (#56) of two residents reviewed for pressure related wound care. The facility census was 63. Actual harm occurred on 03/26/24 when the facility failed to adequately assess and implement pressure ulcer wound care for Resident #56, a new admission who had impaired cognition and bowel incontinence. On 03/28/24 the resident was transferred to the emergency room where hospital staff identified an extensive coccyx/sacral pressure ulcer with surrounding cellulitis and additional concern for osteomyelitis. The facility had not implemented any type of pressure ulcer wound care for the resident prior to the hospitalization. The resident was admitted for wound care intervention with intravenous antibiotic treatment due to the facility's lack of monitoring and adequate wound care following initial…

    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 · Fcited before2026-04-16 · 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

    Based on observation and interviews, the facility failed to serve hot and palatable foods. This affected four residents (Residents #2, #6, #8 and #61) and had the potential to affect all 68 residents residing in the facility. The facility census was 68.Findings include: Interview with Resident #2 on 04/13/26 at 10:41 A.M. revealed the facility's food was The worst food I ever ate in the world. It's cooked until it's leather and dry. Interview with Resident #8 on 04/13/26 at 11:06 A.M. revealed the facility's food was scrambled eggs terrible, tasteless, and not real hot.Interview with Resident #61 on 04/13/26 at 11:11 A.M. revealed the facility's food was not hot, tasteless sometimes, and the meat is hard.Interview with Resident #6 on 04/13/26 at 12:49 P.M. revealed the facility's food was okay sometimes, most of the time it's cold by the time it gets to me. Observation of the test tray with Dietary Manager (DM) #236 on 04/15/26 at 1:09 P.M. revealed the tray consisted of chicken pot pie filling, cauliflower, a biscuit, and a brownie. The pot pie filling was 105 degrees Fahrenheit…

    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 · D2026-04-16 · 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

    Based on observations, interviews, and review of email correspondence, water temperature audit forms and facility policy, the facility failed to maintain adequate hot water temperatures in resident rooms. This affected four residents (Residents #9, #14, #17 and #54) out of 12 residents reviewed for hot water temperatures. The facility census was 68.Findings include:Interview on 04/13/26 at 4:10 P.M. with Resident #9 complained of his hot water not being warm enough when taking a shower and it was uncomfortable. Observation at the time of the interview revealed the hot water temperature in Resident #9's sink was 88 degrees Fahrenheit (F). The Administrator and Director of Maintenance (DM) #248 were notified of the temperature result at the time of the observation. An interview with DM #248 revealed he had increased the hot water tank temperature level.Observation on 04/14/26 at 7:35 A.M. of Resident #9's hot water temperature resulted in a reading of 92 degrees F. The Administrator was notified of the temperature result at the time of the observation.Review of email correspondence…

    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 before2025-05-15 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and review of the facility policy, the facility failed to ensure Resident #63's comprehensive care plan was revised regarding her desire to live in the community and failed to assist Resident #63 with her discharge planning. This affected one resident (#63) out of three residents reviewed for discharge planning. The facility census was 62. Findings include: Review of the closed medical record for Resident #63 revealed an admission date of 12/31/24 with diagnoses including multiple sclerosis (MS), diabetes, anxiety disorder, bipolar disorder, schizoaffective disorder and major depression. Review of the care plan dated 12/31/24 revealed Resident #63's discharge planning was long-term placement. The care plan revealed Resident #63 stated she would stay at the facility, for now. Interventions included allowing resident choices, assessing resident's understanding and ability in safety during transfers, mobility, and activities of daily living, and offering opportunity to verbalize…

    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 · F2024-06-03 · tag F0730 — widespread
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure state-tested nursing aides (STNAs) received annual performance evaluations. This affected two STNAs (#604 and #614) of three reviewed for completed employee files. This had the potential to affect all 63 residents residing in the facility. Findings include: Record review of the employee files for STNA #604 revealed she was hired 12/21/22. Record review of the employee file for STNA #614 revealed she was hired 12/22/22. No documented evidence could be found in either employee file indicating they received annual performance evaluations. Interview with Human Resources Director #663 on 05/29/24 at 4:05 P.M. confirmed the above findings. She said the facility did not perform annual evaluations for their employees.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-06-03 · 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 and staff interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner and the dish machine was monitored to ensure all service ware, cutlery, and utensils were sanitized effectively. This had the potential to affect 63 residents residing in the facility. The facility identified no residents received nothing by mouth. Findings include: An initial kitchen tour was conducted on 05/28/24 between 8:59 A.M. and 9:22 A.M. with Dietary Manager (DM) #655. Observation of the low temperature dish machine revealed the following: • Dietary Worker/Cook #661 did not know what the temperature of dish machine should be or how to test the chemical level. DM #665 tested the dish machine rinse with a test strip usually used for testing Quaternary solutions used in the three compartment sinks and sanitizing buckets. Quaternary solutions should be maintained at 150 to 200 parts per million (ppm) concentration. The test strip did not show any results because it was the wrong type of strip. • Low temperature dish washers use chemical sanitization.…

    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 before2024-06-03 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, facility policy review, and review of the memorandum from the Department of Health and Human Services, the facility failed to initiate and use enhanced barrier precautions (EBP) when appropriate for Residents #56, #262, #264, and #313. This affected four residents (#56, #262, #264 and #313) of seven residents reviewed for infection prevention and control and had the potential to affect all 63 residents residing in the facility. Findings include: 1. Observation and interview on 05/28/24 at 9:08 A.M. with Resident #262 revealed a PICC (peripherally inserted central catheter) in the right arm. There was no EBP posted and no personal protective equipment (PPE) available at the room entrance. Review of the medical record for Resident #262 revealed an admission date of 04/23/24. Diagnoses included osteomyelitis, diabetes mellitus type II, and urinary tract infection. The physician orders and medication administration records from April 2024 to May 2024 indicated an intravenous (IV) antibiotic was infused daily via PICC from admission until…

    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 · E2024-06-03 · tag F0656 — failed to write and follow a full care plan — pattern
    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 interview, observation, record review and review of the facility policy, the facility failed to ensure comprehensive care plans and/or Kardex's were complete for Residents #14, #16, #50, and #52. This affected four residents (#14, #16, #50, and #52) out of 22 resident's care plans reviewed. The facility census was 63. Findings include: 1. Review of the medical record for Resident #16 revealed an admission date of 08/04/21 with diagnoses including congestive heart failure, hypertension, and chronic obstructive pulmonary disease. Review of the care plan dated 08/11/21 revealed Resident #16 was on diuretic therapy due to edema. Interventions included administering diuretic medications as ordered, monitor, document and report any adverse effects, and apply TED hose/embolic stockings (tight stockings applied to lower extremities to reduce edema (swelling caused by fluid trapped in body's tissues) to her bilateral lower extremities as tolerated by donning in the morning and doffing at night. The comprehensive…

    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 · Ecited before2024-06-03 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview, the facility failed to puree all items in a manner that preserved nutrient value and taste. This had the potential to affect the five residents (#13, #18, #31, #46, and #213) identified by the facility as receiving pureed consistency foods. The facility census was 63. Findings include: Observation on 05/29/24 at 11:41 A.M. of the preparation of puree green beans revealed [NAME] #656 added green beans and their cooking water to a blender. There was a lot of cooking water. The green bean mixture was blended. [NAME] #656 checked the consistency and found it was too thin. The cook added food thicker and blended again. This was completed three times. The resulting puree green beans had an appropriate consistency but tasted diluted. This amount of water and thickener also diluted the nutrient density. [NAME] #656 verified there had been too much water in the mixture requiring additional thickener to be needed to reach the correct consistency.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-03 · 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

    Based on observation, record review and interview, the facility failed to provide privacy for urinary catheter drainage bags. This affected three residents (#25, #56 and #264) of four residents reviewed for urinary catheters. The facility census was 63. Findings include: 1. Observation on 05/28/24 at 9:29 A.M. from the hallway outside Resident #25's room revealed Resident #25 lying in bed with a urinary catheter drainage bag secured to the right bedside facing the room entrance door. There was no privacy covering over the urinary drainage bag. Interview on 05/29/24 at 9:31 A.M. with State Tested Nursing Assistant (STNA) #630 verified there was no privacy covering over Resident #25's urinary catheter drainage bag or it was not placed on the opposite side of the bed out of public view. Review of the medical record for Resident #25 revealed an admission date of 11/20/23. Diagnoses included neuromuscular dysfunction of bladder, urinary tract infection, multiple sclerosis, and diabetes mellitus type II. The plan of care dated 11/20/23 indicated Resident #25 had a suprapubic catheter 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-03 · 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 interview, observation, record review and review of the facility policy, the facility failed to ensure Resident #16 and Resident #60's embolic stockings (tight stockings applied to lower extremities to reduce edema) were applied as ordered by the physician. This affected two residents (#16 and #50) out of two residents reviewed for edema. This had the potential to affect five additional residents (#3, #4, #7, #38, and #42) identified by the facility as residents who had orders for embolic stockings. The facility census was 63. Findings include: 1. Review of the medical record for Resident #16 revealed an admission date of 08/04/21 with diagnoses including congestive heart failure, hypertension, and chronic obstructive pulmonary disease. Review of the care plan dated 08/11/21 revealed Resident #16 was on diuretic therapy due to edema. Interventions included administering diuretic medications as ordered, monitor, document, and report any adverse effects, and apply TED hose (embolic stockings) to her…

    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
Show the remaining 14 citations
  • Potential for harm · D2024-06-03 · 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, interview and record review, the facility failed to obtain physician's orders and provide sufficient care for an indwelling urinary catheter. This affected one resident (#264) of four residents reviewed for urinary catheters. The facility census was 63. Findings include: Observation on 05/28/24 at 9:21 A.M. from the hallway outside Resident #264's room revealed Resident #264 lying in bed with a urinary catheter drainage bag secured to the left bedside facing the room entrance door. Interview at the time of the observation with State Tested Nurse Aide (STNA) #630 verified Resident #264 was recently admitted and had an indwelling urinary catheter. Review of the medical record for Resident #264 revealed an admission date of 05/24/24. Diagnoses included pneumonia, chronic kidney disease stage III, and diabetes mellitus. The baseline plan of care completed 05/24/24 indicated Resident #264 had an indwelling urinary catheter. Review of Resident #264's physician's orders for May 2024 revealed no…

    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 · D2024-06-03 · tag F0694 — isolated
    Provide for the safe, appropriate administration of IV fluids 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 interview, observation, record review and review of the facility policy, the facility failed to ensure Resident #16's midline (intravenous catheter inserted in the upper arm with the tip located just below the axilla area) catheter was appropriately monitored and maintained. This affected one resident (#16) out of one resident reviewed for intravenous (IV) access and had the potential to affect two residents (#16 and #313) identified by the facility with IV access. The facility census was 63. Findings included: Review of the medical record for Resident #16 revealed an admission date of 08/04/21 with diagnoses including congestive heart failure, hypertension, and chronic obstructive pulmonary disease. Review of the undated comprehensive care plan for Resident #16 revealed nothing regarding Resident #16 having a midline IV catheter, including monitoring and/or maintaining it. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 had intact cognition and had no IV…

    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 · D2024-06-03 · 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 interview, observation, record review and review of the facility policy, the facility failed to ensure residents had oxygen orders, oxygen was secured safely, and/or residents had oxygen signs indicating oxygen was in use. This affected two residents (#52 and #264) out of two residents reviewed for respiratory care. This had the potential to affect ten residents (#2, #9, #12, #25, #52, #56, #211, #264, #311, and #312) that were identified by the facility with oxygen. The facility census was 63. Findings include: 1. Review of the medical record for Resident #52 revealed an admission date of 04/05/24 with diagnoses including congestive heart failure, hypertension, and/or abnormalities with gait and mobility. Review of the undated comprehensive care plan revealed there was nothing in the care plan regarding Resident #52's use of oxygen. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #52 was cognitively impaired. He wandered one to three days during the seven-day…

    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 · D2024-06-03 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and facility policy review, the facility failed to ensure pharmacy recommendations were addressed by the physician in a timely manner. This affected three residents (#15, #21, and #25) of five residents reviewed for unnecessary medications. The facility census was 63. Findings include: 1. Review of the medical record for Resident #15 revealed an admission date of 11/24/21. Diagnoses included vascular dementia with anxiety, gastrointestinal hemorrhage, insomnia, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident#15 had intact cognition. Review of the 06/12/23 Pharmacist Recommendation to Physician revealed Resident #15 had an order for trazadone 50 milligrams (mg) (antidepressant and sedative). Take a half tablet by mouth daily. The pharmacist recommended that due to multiple problems associated with administering half tablets, the physician consider an alternate dosing regimen so that whole pills were used. 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 · D2023-05-10 · 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 record review and interview, the facility failed to ensure the physician was notified of a significant weight loss for Resident #12. This affected one resident (#12) of seven reviewed for weight loss. The facility census was 54. Findings include: Review of the medical record for Resident #12 revealed an admission date of 12/13/22. Diagnoses included lymphoma, diabetes, hypertension, and hyperlipidemia. Review of the quarterly Minimum Data Assessment (MDS) dated [DATE] revealed Resident #12 was moderately cognitively impaired. He required extensive assistance of two people for bed mobility, total assistance of two people for transfers, extensive assistance of one person for dressing, toilet use and hygiene and supervision and set up help for eating. He was not on a weight loss regime and had no mouth pain or missing teeth. Review of the care plan dated 04/15/23 revealed Resident #12 had a nutritional problem due to diagnosis of diabetes. Interventions included maintaining weight and evaluating and making…

    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 before2023-05-10 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to ensure the fall prevention care plan and resulting interventions were updated for Resident #35. This affected one resident (#35) of four residents reviewed for accidents. The facility census was 54. Findings include: Review of the medical record for Resident #35 revealed an admission date of 12/16/22. Diagnoses included Parkinson's, a history of falling, muscle wasting, and atrophy. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/03/23, revealed Resident #35 had impaired cognition. The resident required extensive assistance of two staff for bed mobility, transfers, toilet use, and personal hygiene. The resident required supervision for locomotion. Review of the fall risk assessments dated 05/02/23, 04/28/23, 04/25/23, 04/20/23, and 03/09/23 revealed the resident was at high risk for falls. Review of the plan of care dated 01/15/23 revealed Resident #35 was at risk for falls due to deconditioning, gait/balance problems, and psychoactive drug use. Interventions included: 02/27/23 - Floor mat…

    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 · D2023-05-10 · tag F0661 — isolated
    Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, interview, and facility policy review the facility failed to ensure discharges were thoroughly documented in the medical record. This affected one resident (#55) of four residents reviewed for discharge. The facility census was 54. Findings include: Review of the medical record for Resident #55 revealed an admission date of 11/08/21 and a discharge date of 02/03/22. Diagnoses included congestive heart failure (CHF), dementia, depression, and anxiety. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 11/10/21, revealed Resident #55 had impaired cognition. He required extensive assistance of two people for bed mobility, transfers, and toilet use, extensive assistance of one person for dressing and hygiene and supervision and set-up help for eating. Review of the discharge care plan dated 11/16/21 revealed Resident #55's plan was to discharge home. Review of the physician order dated 02/03/22 revealed an order to discharge home without home health care. Interview on 05/10/23 at 8:39 A.M. with Social Service Designee (SSD) #214 revealed she had…

    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 · D2023-05-10 · 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 record review, interview, and facility policy review the facility failed to ensure Resident #26 received routine showers per preference and as scheduled. This affected one resident (#26) of four residents reviewed for showers/activity of daily living care. The facility census was 54. Findings include: Review of the medical record for Resident #26 revealed an admission date of 11/28/22. Diagnoses included Parkinson's disease, glaucoma, diabetes, and heart disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 had moderately impaired cognition. He required extensive assistance of one person for bed mobility, transfers, dressing, and toilet use and limited assistance of one person for hygiene. Review of the facility shower schedule revealed Resident #26 was scheduled to receive a shower every Wednesday and Sunday. Review of the shower sheets for Resident #26 revealed the resident received a shower on 03/05/23, 03/15/23, 03/22/23, 03/26/23, 04/05/23, 04/09/23,…

    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 · Dcited before2023-05-10 · 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 record review, interview, and facility policy review the facility failed to ensure interventions were in place to promote healing of a pressure ulcer for Resident #28. This affected one resident (#28) of two residents reviewed for pressure ulcers. The facility census was 54. Findings include: Review of the medical record for Resident #28 revealed an admission date of 11/29/18. Diagnoses included anxiety, stroke affecting the right dominant side, depression, and gastric ulcer. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #28 required extensive assistance of two people for bed mobility, total assistance of two people for transfers and toilet use, total assistance of one person for dressing and hygiene and extensive assistance of one person for eating. She had a stage three pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon or muscle are not exposed, slough may be present but does not obscure the depth of tissue loss, may include…

    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 · D2023-05-10 · 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, and interview the facility failed to maintain interventions to prevent Resident #258's fall. This affected one resident (#258) out of three residents reviewed for falls. The facility census was 54. Findings include: Review of the medical record revealed Resident #258 was admitted on [DATE] with diagnoses including follicular lymphoma, cancer of esophagus, chronic kidney disease, anemia, high blood pressure, and esophageal reflux disease. A review of Resident #258's fall assessment dated [DATE] indicated he was at moderate risk for falls. A review of Resident #258's clinical record indicated he sustained a fall on 04/30/23. There was no plan of care initiated to attempt to prevent falls until 05/07/23. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #258 had balance problems during transition indicated transfers between bed and chair were not steady and only able to stabilize with staff assistance. A plan of care was triggered to be initiated to…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-10 · 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, interview, and facility policy review the facility failed to follow recommendations to ensure Resident #12 maintained weight or did not continue to lose weight. This affected one resident (#12) of seven resident reviewed for weight loss. The facility census was 54. Findings include: Review of the medical record for Resident #12 revealed an admission date of 12/13/22. Diagnoses included lymphoma, diabetes, hypertension, and hyperlipidemia. Review of the quarterly Minimum Data Assessment (MDS) dated [DATE] revealed Resident #12 was moderately cognitively impaired. He required extensive assistance of two people for bed mobility, total assistance of two people for transfers, extensive assistance of one person for dressing, toilet use and hygiene and supervision and set up help for eating. He was not on a weight loss regime and had no mouth pain or missing teeth. Review of the care plan dated 04/15/23 revealed Resident #12 had a nutritional problem due to diagnosis of diabetes. Interventions…

    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 · Dcited before2023-05-10 · 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, interview, and facility policy review the facility failed to follow infection control standards for Resident #28 during wound care to prevent possible cross-contamination of germs. This affected one resident (#28) out of three residents reviewed for wound care. The facility census was 54. Findings include: Review of the medical record revealed Resident #28 was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis following a stroke affecting the right dominant side, aphasia, anxiety, dysphagia, gastronomy tube, central pain syndrome, poly neuropathy, obesity, osteoarthritis, coagulation deficit, hearing loss, anemia, fatty liver, kidney cyst, peripheral vascular disease, depression, myasthenia gravis, uterine cancer, and hyperlipidemia. Resident #28 developed the coccyx wound in the facility on 10/06/21. A review of Resident #28's wound assessment dated [DATE] indicated the presence of a stage III pressure ulcer (full thickness tissue loss, subcutaneous fat…

    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
  • No harm found · C2024-06-03 · tag F0606 — failed to not employ staff found guilty of abuse — widespread
    Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure all staff members received reference checks before hire. This affected four employees, Licensed Practical Nurse (LPN) #642, State-Tested Nursing Aide (STNA) #604, STNA #614, and Maintenance Director (MD) #603, of six employees reviewed for completed employee files. This had the potential to affect all 63 residents residing in the facility. Findings include: Record review of the employee files for LPN #642, STNA #604, STNA #614, and MD #603 revealed no evidence the facility made reference checks or other attempts to check information from past or current employers before hiring the staff members. Interview with Human Resources Director #663 on 05/29/24 at 4:05 P.M. confirmed the above findings, and follow-up interview with her on 05/30/24 at 8:25 A.M. revealed the facility could not locate any documented evidence reference checks were attempted for the affected employees.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2024-06-03 · tag F0567 — failed to protect residents' money held by the home — pattern
    Honor the resident's right to manage his or her financial affairs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure they received signed and witnessed authorizations before managing resident funds. This affected three residents (#55, #39, and #61) of five residents reviewed for funds management. The facility census was 63. Findings include: 1. Record review of Resident #55 revealed he had $50.00 deposited in the facility's resident trust account. The facility furnished an authorization form that did not include any witness signature. 2. Record review of Resident #39 revealed she had $5.00 deposited in the facility's resident trust account. The facility could not furnish documented evidence of a signed or witnessed authorization form permitting them to manage her personal money. 3. Record review of Resident #61 revealed he previously had funds managed by the facility in a trust account closed on 10/12/23. The facility could not furnish documented evidence of a signed or witnessed authorization form permitting them to manage his personal money. Interview with Human Resources Director #663 on 05/29/24 at 1:50 P.M. confirmed 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.

    Resident Rights 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.

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. 1 Medicare payment denial on record.

  • Medicare payment denial — starting 2024-06-29 for 13 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.

Part of a chain

This home belongs to AOM HEALTHCARE — 20 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 52.7-0.7 vs chain
Health inspection 3 of 52.3+0.7 vs chain
Staffing 1 of 51.6-0.6 vs chain
Quality measures 4 of 54.8-0.8 vs chain
The other 19 homes this chain runs (chain average 2.7★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
GOLDSTEIN, JEFFERYIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; W-2 MANAGING EMPLOYEE; CORPORATE OFFICER49%since 03/04/2021
SHERMAN, LEAIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST49%since 03/04/2021

CMS files one row per role, so the 4 rows in the source record cover these 2 parties — each is shown once here with every role it holds. Nothing is omitted.

Follow the money — this home’s finances

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

$5.9M
Net patient revenuemost recent cost report
-2.1%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 66%Medicare 10%Other / private 24%

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

$301per resident / day
operating cost
$9,152per month
≈ monthly operating cost
$295per 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 366326. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-16, 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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