Spring Creek Nursing And Rehabilitation Center LLC
401 N Broadway St, Green Springs, OH 44836 · For profit - Limited Liability company · 120 certified beds · (419) 639-2626 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- it has an abuse, neglect, or exploitation citation (F0602), cited Mar 2026
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $77,618 in federal fines (most recent 2024-09-24)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 9.7% | 5.3% | 15.4% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 4.8% | 6.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.0% | 0.2% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.4% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 71.6% | 30.1% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 0.8% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 10.2% | 6.1% | 16.1% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 43.3% | 25.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 13.0% | 3.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 24.3% | 21.4% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 13.6% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 88.7% | 75.6% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 15.1% | 24.9% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 13.3% | 12.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.63 | 1.73 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.41 | 1.80 | 1.80 | better |
‡ 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.
60.9% 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 25 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 36.4% 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 22 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.26 therapist hours per resident per day in 2026Q1 — more than 38% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 12% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 60.9%CMS range 39.4–80.3 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.9%CMS range 6.4–13.6 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 36.4% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 22.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 40.9% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 89.3% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 10.7% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.94 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 120 beds and averages 71.6 residents a day — about 60% occupied, or roughly 48 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.72 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.35 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.19 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 3.45 hrs/resident/day on weekends vs 3.83 on weekdays — 10% thinner on weekends. RN hours go from 0.40 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 41% is about the same as the national median of 45%.
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 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.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
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.
31 citations, most serious first. The 11 most serious are shown; the remaining 20 are one tap away and print in full.
- Immediate jeopardy · J2024-09-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of facility incident investigations with witness statements, review of staff education, staff interviews, review of a resident handbook, review of a facility Self-Reported Incident (SRI), and review of facility smoking policies, the facility failed to ensure Resident #75 who had a known history of smoking with oxygen on, was assessed as an independent smoker, exhibited safe smoking practices and did not smoke while wearing oxygen. This resulted in Immediate Jeopardy and serious life-threatening harm, injuries and/or death when Resident #75 lit a cigarette while wearing oxygen therapy via nasal cannula, in the designated smoking area. Resident #75's oxygen ignited and set Resident #75 on fire with the oxygen. Resident #75 sustained singed facial hair, and the skin around his mouth, nose, and bilateral cheeks was charred black. Resident #75, while being treated by the local emergency medical squad, began to experience a deteriorating airway and adventitious lung sounds…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-09 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, staff interview, police officer interview, review of Self-Report Incident (SRI) #269318, review of the facility investigation, and review of the facility policy, the facility failed to protect a resident from misappropriation. This affected one resident (#2) of three reviewed for misappropriation. The facility census was 71.Findings include: Review of the medical record for Resident #2 revealed an admission date of 12/04/13. Diagnoses included Multiple Sclerosis (MS), diabetes mellitus type two, chronic obstructive pulmonary disease (COPD), heart failure, chronic kidney disease (CKD) stage three, atrial fibrillation (A-fib), hypertension, and peripheral vascular disease (PDV). Review of the quarterly Minimum Data Set (MDS) dated [DATE] for Resident #2 revealed the resident had mild cognitive impairment. Review of the statement submitted by Resident #2, dated 01/02/26, revealed the resident reported she reviewed her most recent bank statement and it had charges…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-15 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident and staff interview, review of resident shower sheets and shower schedules, and facility policy review, the facility failed to ensure residents who were dependent on staff for bathing received showers on their scheduled days per their preference. This affected three (#17, #25, and #67) of four residents reviewed for showers. The facility census was 68. Findings include: 1. Review of the medical record for Resident #17 revealed an original admission date of 12/04/13 with re-admission to the facility on [DATE]. Diagnoses included multiple sclerosis, chronic obstructive pulmonary disease (COPD) and atrial fibrillation. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. The resident was assessed to require maximal assistance with showers and was dependent on staff to transfer into the shower. Review of the care plan dated 07/26/22 revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-08-27 · tag F0919 — failed to provide a working call system — patternMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, resident and staff interviews, and review of the facility policy, the facility failed to ensure the resident's call devices were functioning in their bathroom and/or bedrooms and failed to ensure the residents had accessibility and/or functionality of call devices in the shower rooms. This affected three (#22, #23, and #24) of five residents reviewed for call lights and had the potential to affect the residents who utilize the showers on first and third floor. The facility census was 74.1. Observation and interview on 08/14/25 at 8:45 A.M. revealed Resident #22's bathroom call light did not work. Resident #22 stated he would just wait for staff to come back after he was toileted. He could not recall if he used his call light or not. Interview on 08/14/25 at 11:10 A.M. with Plant Operation Director (POD) #102 confirmed Resident #22's bathroom call light did not work. 2. Observation and interview on 08/14/25 at 8:30 A.M. revealed Resident #23's bathroom call light was in the pulled position and the light was not functioning. Interview on 08/14/25 at 8:30 A.M.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-27 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews, record review, and review of the facility policy, the facility failed to ensure the residents had a homelike environment. This affected three (#22, #23,and #24) of four residents reviewed for homelike environment. The facility census was 72.1. Review of the medical record for Resident #22 revealed a re-admission on [DATE]. Diagnoses included chronic obstructive pulmonary disease and seizures. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 had severe cognitive impairment.Observation and interview on 08/14/25 at 8:45 A.M. of Resident #22's bathroom revealed a sink with a built in soap dispenser holder without a soap container in the holder. There was not any soap or paper towels available. Interview on 08/14/25 at 8:45 A.M. with Resident #22 stated she ambulates with one assist to the restroom. Resident #22 stated to wash his hands, the Certified Nursing Aide (CNA) would have to get a washcloth and soap from outside…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-27 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 medical record review and staff interview, the facility failed to develop a care plan based on Resident #23's medical needs. This affected one (#23) of one resident reviewed for care plans. The facility census was 72.Review of the medical record for Resident #23 revealed an admission on [DATE]. Diagnoses included type I diabetes mellitus (DM). Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was cognitively intact. Review of Resident #23's physician orders dated 06/05/25 revealed an order for insulin aspart injection solution 100 units (u) per milliliter (ml). Inject 100 units subcutaneously as needed for type I DM, administered through insulin pump. Review of the care plan for Resident #23 dated 06/25/25 revealed there was no care plan developed for Resident #23's diagnosis of type I DM, use of insulin for DM and management of Resident #23's insulin pump. Interview on 08/14/25 at 8:30 A.M. with Resident #23 revealed there have been times when she has low…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-05-30 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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 observation, interview, and policy review, the facility failed to maintain a clean environment in the shower rooms. This had the potential to affect all residents residing One South and One [NAME] (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, and #74). The facility census was 73. Findings include: Observation on 05/28/25 from 1:31 P.M. to 2:21 P.M. revealed the shower room on One [NAME] with a brown substance observed on the back of the shower chair seat. Shower bed with brown residue underneath on the drip cloth running the length of the bed and peg-tube cap under the shower bed mattress. Observation on 05/29/25 at 4:15 P.M. of One South shower room revealed brown sticky substance on the floor in the shower area, one tile missing on the shower wall, brown/black substance on the ceiling above the foot washer, brown substance on the wall of the foot washer, three dirty washcloths in the tub, and standing water…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-06 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and facility policy, the facility failed to notify a resident representative of a change of condition. This affected one (Resident #41) of three residents reviewed for notification of change. The facility census was 69. Findings include: Review of the medical record revealed Resident #41 was admitted on [DATE]. Diagnoses included acute and chronic respiratory failure, unspecified combined systolic (congestive) and diastolic (congestive) heart failure, lymphedema, chronic kidney disease stage three, acute respiratory failure with hypoxia, bilateral primary osteoarthritis of knee, fibromyalgia, essential primary hypertension, and hyperlipidemia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of the nursing note dated 11/18/24 at 12:29 A.M. revealed Resident #41 complained of shortness of breath and her chest feeling heavy. The resident's oxygen saturation was in the 70's and 80's at two liters of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-09-24 · tag F0835 — failed to run the facility competently — widespreadAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of the facility's billing statements, review of email communication, vendor interviews, and staff interviews, the facility failed to operate the facility in a manner to ensure facility bills were being paid in a timely manner. This had the potential to affect all 73 residents in a facility with a census of 73. Findings include: 1. Review of the facility's electric invoice dated 07/29/24 revealed an amount of $438,869.15 was due by 09/19/24 with a disconnection notice provided which states the facility's electric service payment is past due and the electric service could be disconnected unless payment of $409,334.97 is made by 08/19/24. Review of the facility's electric invoice dated 08/30/24 revealed an amount of $436,010.41 was due by 09/20/24 with a disconnection notice provided which stated the facility's electric service is payment is past due and the electric service could be disconnected unless payment of $403,795.52 is made by 09/20/24. Review of the facility's payments to the electric service provider revealed payments in the amount of $25,000 on 03/20/24,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-02-15 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, medical record review, the facility failed to ensure the electronic medical record (EMR) accurately reflected physician orders and treatments provided to residents. This affected four (#49, #71, #74, and #77) of 20 residents reviewed for an accurate medical record. The facility census was 75. Findings include: 1. Review of the medical record revealed Resident #77 was admitted on [DATE]. Diagnoses included encounter for other orthopedic aftercare, other fracture of the left lower leg, subsequent encounter for closed fracture with routine healing, nontraumatic subarachnoid hemorrhage, unspecified fracture of the sacrum initial encounter for closed fracture, lesion of the radial nerve of the left upper limb, and cutaneous abscess of the left lower limb. Review of the Minimum Data Set (MDS) assessment, dated 01/17/24, revealed the resident was cognitively intact. Review of Resident #77's physician order, dated 01/10/24 to 02/13/24, revealed an order 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.
- Potential for harm · D2024-02-15 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and review of a facility policy, the facility failed to ensure resident dignity was maintained. This affected one (#24) of one residents reviewed for dignity. The facility census was 75. Findings include: Review of the medical record revealed Resident #24 was admitted on [DATE]. Diagnoses included Parkinson's disease without dyskinesia, hypertensive heart and chronic kidney disease with heart failure, peripheral vascular disease, chronic kidney disease stage three, unspecified dementia, major depressive disorder, and lymphedema. Review of the Minimum Data Set (MDS) assessment, dated 11/08/23, revealed the resident was moderately cognitively impaired. Resident #24 was always incontinent of bowel and bladder and required substantial/maximal assistance with toileting. Observation on 02/13/24 at 1:39 P.M. revealed Resident #24 was observed from the hallway with the door to the room open. Resident #24 was laying on her left side with her backside facing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 20 citations
- Potential for harm · D2024-02-15 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each 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 observation, medical record review, resident interview, and staff interview, the facility failed to ensure timely response to activated call lights and failed to ensure call lights were within reach of residents who were capable of using the call light and were dependent for care. This affected two (#1 and #4) of three residents reviewed for call lights. The facility census was 75. Findings include: 1. Review of the medical record for Resident #1 revealed an admission date of 05/16/95 with diagnoses of hemiplegia and morbid obesity. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had intact cognition and was dependent on staff for toileting. Review of the current care plan revealed Resident #1 had an activities of daily living (ADL) self-care deficit due to left side hemiplegia. Interventions included to provide a bedpan or bedside commode. Interview and observation on 02/12/24 at 7:30 P.M. with State Tested Nurse Aide (STNA) #315 confirmed the call light…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-15 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure advanced directives were consistent throughout the medical record. This affected one (#49) of 24 residents reviewed for advanced directives. The facility census was 75. Findings include: Review of the medical record for Resident #49 revealed an admission date of 12/08/23 with diagnoses of Alzheimer's disease and vascular dementia. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 had severely impaired cognition. Review of the electronic medical record (EMR) revealed Resident #49 had a physician order for Do Not Resuscitate Comfort Care (comfort measures to be administered before, during, or after the time of cardiac or respiratory arrest). Interview on 02/13/24 at 4:39 P.M. with Registered Nurse (RN) #297 confirmed there was a paper copy of Resident #49's advance directive in her paper medical record. The paper copy revealed Resident #49's code status was Do Not Resuscitate Comfort…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-15 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, medical record review, and review of a facility policy, the facility failed to ensure only physician ordered tracheostomy supplies were readily available to staff for respiratory needs, and failed to ensure supplemental oxygen tubing was changed as ordered. This affected three (#71, #74, and #76) of four residents reviewed for respiratory care. The facility census was 75. Findings include: 1. Review of the medical record for Resident #76 revealed an admission date of 11/16/23. Diagnoses included cerebral palsy, spastic quadriplegia, hypertension, dysphagia, end stage renal disease with dependence on dialysis, and respiratory failure with hypercapnia and dependence on a respirator. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #76 was assessed with cognitive impairment with memory loss. Resident #76 was dependent on staff for all care and required oxygen therapy and suctioning via tracheostomy (a surgical airway passage…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-15 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure 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
Based on medical record review, staff interview, pharmacy staff interview, and review of a pharmacy agreement document, the facility failed to ensure irregularities were identified during monthly drug regimen reviews and those irregularities were reported to the facility. This affected one (#20) of six residents reviewed for pharmacy monthly drug regimen reviews. The facility census was 75. Findings include: Review of the medical for Resident #20 revealed an admission date of 03/24/20 with a diagnosis of hypokalemia (low potassium). Review of Resident #20's physician orders revealed the resident was ordered the supplement potassium tablet 20 milligrams (mg) in December 2023, January 2024, and currently in February 2024. Review of the monthly physician progress notes for Resident #20 for December 2023 and January and February 2024 the physician reviewed the medication list for Resident #20 which included an order for potassium tablet 20 mg and contained a plan to continue the potassium supplement. Review of the monthly medication regimen review (MRR) documents for Resident #20 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.
- Potential for harm · D2024-02-15 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, medical record review, review of pharmacy packing slips, review of a pharmacy provider agreement, and review of a facility policy, the facility failed to ensure medications were available and administered as ordered by the physician resulting in significant medication errors. This affected one (#77) of two residents observed during medication administration and two (#76 and #331) of five residents reviewed for medications. The facility census was 75. Findings included: 1. Review of the medical record for Resident #76 revealed an admission date of 11/16/23. Diagnoses included cerebral palsy, spastic quadriplegia, hypertension, dysphagia, end stage renal disease with dependence on dialysis, and respiratory failure with hypercapnia with dependence on a respirator. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #76 was assessed with cognitive impairment with memory loss, was dependent on staff for all care, was dependent on supplemental…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-15 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and review of a facility policy, the facility failed to ensure medications were stored in a safe and secure manner. This affected two (#8 and #53) of four residents reviewed for medication storage. The facility census was 75. Findings include: 1. Review of the medical record revealed Resident #8 was admitted on [DATE]. Diagnoses included unspecified injury at the C5 level of cervical spinal cord, quadriplegia, chronic obstructive pulmonary disease, essential (primary) hypertension, hypertensive heart disease with heart failure, and type two diabetes mellitus without complications. Review of the Minimum Data Set (MDS) assessment, dated 12/22/23, revealed Resident #8 was cognitively intact. Review of the most recent care plan revealed Resident #8 had depression due to physical limitations. Interventions included to administer medications as order and monitor/document for side effects and effectiveness. The resident declines medications due to paranoia…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-30 · tag F0712 — isolatedEnsure that the resident and his/her doctor meet face-to-face at all required visits.
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 visited residents every 60 days. This affected one (Resident #87) of three residents reviewed for physician services. The facility census was 79. Findings include: Review of Resident #87's medical record revealed an admission date of 06/09/21. Diagnosis included quadriplegia, stage four pressure ulcer to the sacral and buttocks, and chronic obstructive pulmonary disease. Review of Resident #87's quarterly Minimum Data Set (MDS) dated [DATE] revealed his cognition was intact. Review of Resident #87's medical record revealed the resident was seen by the Certified Nurse Practitioner (CNP) monthly and as needed. The medical record had only one physician progress note dated 09/21/23. During interview on 11/29/23 at 8:44 A.M., interview with Resident #87's family revealed they were not aware of any physician visits, but that the CNP visited regularly and as needed. During interview on 11/29/23 at 3:48 P.M., the Director of Nursing (DON)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2021-11-01 · tag F0563 — failed to protect the right to visitors — widespreadHonor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
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, record review, review of the Resident Council meeting minutes, family and staff interview and review of the facility policy, the facility failed to allow one (#8) resident to have visitors at the time of the resident and visitor's choosing. This deficient practice had the potential to affect 59 of 59 residents who reside in the facility. Findings include: Review of Resident #8's medical record revealed an admission date of 09/05/11. Diagnoses included hemiplegia and hemiparesis, cerebral vascular accident, dysphagia, diabetes mellitus, epilepsy, lymphedema and a history of breast cancer. Review of Resident #8's quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident was rarely or never understood. The resident was totally dependent on toilet use, personal hygiene, bed mobility, transfers, Interview with Resident #8's family on 10/26/21 at 10:47 A.M., revealed the facility did not allow visitors after 5:00 P.M. The family stated due to their work schedule, they had limited…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2021-11-01 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 record reviews, observations, staff interviews, review of the facility policy, review of the Legionella guide, and review of the map and census, the facility failed to maintain standards of infection control practices during a clean dressing change for one (#14) resident. The facility failed to ensure resident care equipment was clean and stored in an appropriate manner for one (#32) resident to prevent potential infections. The facility also failed to implement the Legionella guide to ensure the water supply was adequate. In addition, the facility failed to ensure staff and visitors wore proper personal protective equipment (PPE) during a COVID-19 outbreak in the facility, including the staff swabbing for COVID-19 tests of unvaccinated staff. This deficient practice had the potential to affect 59 of 59 residents who reside in the facility. Findings include: 1. Review of the record for Resident #14 revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic respiratory…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2021-11-01 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interview and review of the facility policy, the facility failed to maintain resident rooms and the resident smoking area in a sanitary and comfortable manner. This affected eight (#12, #20, #32, #36, #38, #50, #53, and #54) of 59 residents who reside in the facility. The total facility census was 59. Findings include: Observation on 10/25/21 at 11:22 A.M., revealed a heavy build up of dust on the television entertainment stand, unfolded clothes piled on the bed, four soiled clothing protectors laying on the bed, and the sliding closet doors were off the track. Resident #38 was not able to use the closet as the doors will not open or close. This was verified with the Director of Environmental Services (DES) #500. Observation on 10/25/21 at 11:25 A.M. of Resident #32's bathroom, revealed a dirt and grime build up on the bathroom floor and a dried brown substance on the toilet seat. This was verified with State Tested Nursing Assistant (STNA) #200. Observation on 10/27/21 at 11:48 A.M. of the outside smoking area, revealed cigarette butts laying on the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-11-01 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff and resident interviews, review of the facility policy and review of the facility Self-Reported Incidents (SRI's), the facility failed to report an allegation of verbal abuse involving one resident to the State Agency. This affected one (#47) of one resident reviewed for abuse. The total facility census was 59. Findings include: Review of Resident #47's medical record revealed an admission date of 12/04/20. Diagnoses included congestive heart failure, chronic obstructive pulmonary disease, diabetes mellitus, coronary bypass, chronic pain syndrome, malnutrition, and a history of falls. Review of Resident #47's quarterly Minimum Data Set, dated [DATE]. revealed the resident had a high cognitive function and required a one person assist for bathing. Interview with Resident #47 on 10/25/21 at 11:02 A.M., revealed the resident stated a nurse was verbally abusive to her on 10/23/21, regarding showers. She indicated the nurse told her they did not have time to do showers and was verbally…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-11-01 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and staff interview, the facility failed to properly position one resident during a meal to ensure she was able to feed herself appropriately. This affected one (#46) of one resident observed for meals. The total facility census was 59. Findings include: Review of the Resident #46's record revealed the resident was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, diabetes, seizure disorder, peripheral vascular disease, and schizophrenia. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE], revealed Resident #46 scored a 13 on the Brief Interview for Mental Status (BIMS), indicating she had moderate cognitive deficits. The resident required extensive assistance of two staff for bed mobility and transfers and required setup for eating and can feed herself. Review of the plan of care updated 09/03/21, indicated Resident #46 had an activities of daily living (ADL) self-care performance deficit due to fatigue, muscles impairment,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-11-01 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and staff interviews, the facility failed to ensure compression stockings were applied as ordered for one resident. This affected one (#46) of two residents reviewed for assistive devices. The total facility census was 59. Findings include: Review of Resident #46's record revealed the resident was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, diabetes, seizure disorder, peripheral vascular disease, and schizophrenia. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE], revealed Resident #46 scored a 13 on the Brief Interview for Mental Status (BIMS), indicating she had moderate cognitive deficits and required extensive assistance of two staff for bed mobility, dressing, and transfers. Review of the plan of care updated 09/03/21, revealed Resident #46 had an activities of living (ADL) self-care performance deficit due to fatigue, muscles impairment, activity intolerance, and limited mobility. The goal was for the resident to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-11-01 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and staff interviews, the facility failed to implement interventions that included a palm protector for one resident to ensure his hand contractures did not worsen. This affected one (#19) of one resident observed for contractures. The total facility census was 59. Findings include: Review of the record for Resident # 19 revealed the resident was admitted to the facility on [DATE]. Diagnoses included traumatic brain injury, right dominate side hemiplegia aphagia, and contracture of the right hand. Review of the quarterly Minimum Data Set (MDS) assessment dated 10 06/21, revealed the residents short and long term memory was in tact. His decision making was severely impaired and he wsa totally dependent on staff for all activities of Daily living (ADL's) including eating. Review of the plan of care updated 10/6/21, revealed Resident #19 had an activity of daily living (ADL) self-care performance deficit due to decline in fine motor skills, balance, and contractures. The goal…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-11-01 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interview and review of the facility policy, the facility failed to ensure the medication was stored properly and in locked compartments. This affected one (#257) of one residents medication that was not secured. The total facility census was 59. Findings include: Observation of the first floor nurses station on 10/26/21 at 9:46 A.M., revealed a blistered package of Mycophenolic Acid (immunosuppressive for organ transplant resident) 360 milligram tablets were on the counter unattended. The package contained eight pills. Further observation revealed there was no staff at the nurses station or the hallways surrounding the area. Interview with Registered Nurse #200 on 10/26/21 at 9:58 A.M., verified the medication was left unattended and was accessible to residents. Review of the facility policy titled, Storage of Medications, dated April 2019, revealed the facility stores all drugs and biological's in a safe, secure, and orderly manner. Drugs and biological's used in the facility were stored in locked compartments under proper temperature, light and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-11-01 · tag F0908 — failed to keep essential equipment working — isolatedKeep all essential equipment working safely.
What the surveyor found here — the official record, unedited, may be distressing
Based on observations, staff interview and review of the facility policy, the facility failed to maintain one residents bed in safe manner. This affected one (#257) of one residents bed observed during the environmental tour. The total facility census was 59. Findings include: Observation of Resident #21's bed on 10/26/21 at 8:48 A.M., revealed the resident's bed control was laying on the floor and was noted to have frayed and exposed wires. The frayed and exposed wires were approximately six inches from the remote down the cord with red and blue wires exposed. Interview with Registered Nurse #200 on 10/26/21 at 9:01 A.M., verified the frayed and exposed wires on Resident #21's bed remote were a danger and she would alert maintenance immediately. Review of the undated facility policy titled, Red Tagging of Equipment Policy, revealed if equipment was not functioning properly or the sticker was out of date, place a red tag on the item with the description of what the issue was.
- Potential for harm · E2019-04-18 · tag F0758 — failed to limit and justify psychotropic drugs — patternImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and policy review, the facility failed to ensure residents were free from unnecessary medications when the facility failed to evaluate and receive a new physicians order every 14 days for the anti-anxiety medication, the facility failed to ensure gradual dose reductions (GDR) were attempted for residents receiving psychotropic medications and failed to ensure behaviors were monitored for residents receiving psychotropic medications. This affected four (#43, #14, #15 and #48)) out of five residents reviewed for unnecessary medications. The facility identified 18 residents that received anti-anxiety medication and 10 residents receiving psychotropic medications. Facility census was 52. Findings include: 1. Review of Resident #43's medical record revealed an admission date of 08/01/18. Diagnosis included chronic pain syndrome, panic disorder, acute respiratory failure, panic disorder, and ventilator dependence. Review of Resident #43's quarterly Minimum Data Set (MDS)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2019-04-18 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview and policy review, the facility failed to maintain infection control measures as evidence by a resident's ventilator tubing lying on the ground. This affected one (#26) out of one residents reviewed for respiratory care. The facility identified 17 residents requiring ventilators for respiratory failure. In addition, the facility failed to disinfect resident shared glucometer's per manufacturer recommendations. This had the potential to affect five (#14, #21, #39, #9 and #30) residents who utilize a shared blood glucose testing device (glucometer) on the first floor. The facility census was 52. Findings include: 1. Review of Resident #26's medical record revealed an admission date of 02/07/19. Diagnosis included chronic respiratory failure with dependence on ventilator, sepsis, chronic kidney disease stage 3 with dialysis, lymphedema, diabetes mellitus type 2 and atrial fibrillation. Review of Resident #26's admission Minimum Data Set (MDS) dated [DATE]…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-04-18 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff and resident interview and facility policy review, the facility failed to maintain a supply of residents pain medications to adequately maintain the residents pain and comfort. This affected one (#43) out of three residents reviewed for pain medications. The facility identified 44 residents that received pain medication. The facility census was 52. Findings include: Review of Resident #43's medical record revealed an admission date of 08/01/18. Diagnosis included chronic pain syndrome, panic disorder, acute respiratory failure, panic disorder, and ventilator dependence. Review of Resident #43's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a high cognitive function. The resident required an extensive assistance in all activities of daily living except eating. Resident #43 received opioid medication seven days in the last week. Review of Resident #43's most recent care plan revealed the resident had chronic pain related to complaints of headaches and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-04-18 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff and resident interview and facility policy review the facility failed to maintain a supply of residents pain medications to adequately maintain pain and comfort and failed to ensure medications are administered as physician ordered. This affected two (#43 and #29) out of three residents reviewed. The facility identified 44 residents requiring pain medication and three residents requiring antibiotics. The facility census was 52. Findings include: 1. Review of Resident #43's medical record revealed an admission date of 08/01/18. Diagnosis included chronic pain syndrome, panic disorder, acute respiratory failure, panic disorder, and ventilator dependence. Review of Resident #43's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a high cognitive function. The resident required an extensive assistance in all activities of daily living except eating. Resident #43 received opioid medication seven days in the last week. Review of Resident #43's most recent…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$77,618 in federal fines across 1 penalty.
- $77,618 — penalty dated 2024-09-24
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
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| SC OP HOLDINGS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 12/18/2020 |
| A&C EINHORN FAMILY TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 25% | since 12/18/2020 |
| AE SC HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 25% | since 12/18/2020 |
| BRICK, MICHAEL | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CONTRACTED MANAGING EMPLOYEE; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | NO PERCENTAGE PROVIDED | since 12/18/2020 |
| EINHORN, VIVIAN | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 25% | since 12/18/2020 |
| KOENIG, JOSHUA | Individual | CONTRACTED MANAGING EMPLOYEE; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 12/18/2020 |
CMS files one row per role, so the 11 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.
3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.4M paid to related parties — landlords or management companies under common ownership — equal to about 12% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OH
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Ohio Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 365101. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-02-15, 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.