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Brethren Retirement Community

750 Chestnut Street, Greenville, OH 45331 · Non profit - Corporation · 80 certified beds · (937) 547-8000 Medicare & Medicaid certified

Call the home — (937) 547-8000 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Apr 2025Behavioral-health or dementia-care citation — no harm found (F0758)2 actual-harm citations1 Medicare payment denial
Insights

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

In its favor
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Apr 2025
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (20) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)

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

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

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

Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
716 Sweitzer St · (937) 547-2212 · Call to confirm hours
Pharmacy
Grocery
1120 Sweitzer St · (937) 548-9214 · Call to confirm hours
Park
871 Gray Ave · Typically dawn to dusk
Place of worship
421 Central Ave · (937) 548-3583

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 3 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 4 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 2 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating2★
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 increased22.7%5.3%15.4%worse than state — see note marked double-dagger below the table
Long-stay residents who lose too much weight5.8%6.2%5.4%typical
Long-stay residents with a catheter left in their bladder0.0%0.2%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection2.1%0.4%2.0%typical
Long-stay residents with depressive symptoms3.6%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 injury8.7%3.2%3.3%worse
Long-stay residents whose ability to walk worsened30.7%6.1%16.1%worse than state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication21.5%25.5%18.9%worse
Long-stay residents given the seasonal flu vaccine98.4%94.5%95.3%typical
Long-stay residents with pressure ulcers0.9%3.4%4.7%better
Long-stay residents with worsening bladder/bowel control29.0%21.4%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table10.1%8.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine64.4%75.6%79.4%worse
Short-stay residents rehospitalized after admission32.9%24.9%22.6%worse
Short-stay residents with an outpatient ER visit18.5%12.9%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.191.731.67worse
Long-stay outpatient ER visits per 1,000 resident days4.151.801.80worse

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.

65.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 122 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

65.4%U.S. median 51.5%
Got home and stayed home
9.8%U.S. median 10.7%
Went back to hospital
60.4%U.S. median 56.6%
Met the expected recovery
0.26U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 60.4% 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 53 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 37% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 1% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF65.4%CMS range 58.3–73.651.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.8%CMS range 7.0–13.610.7%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 discharge60.4%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 discharge69.8%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 discharge50.9%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 identified55.7%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 setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this 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 discharge100.0%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 stay1.4%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization5.7%CMS range 3.4–10.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.971.02Oct 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

0.57
RN hours/ resident / day
1.45
LPN hours/ resident / day
2.35
Aide hours/ resident / day
4.37
Total nurse hours/ resident / day
0.32
RN hoursweekends
51.5%
Total nursing turnover
27.3%
RN turnover

How full it usually is: this home is certified for 80 beds and averages 71.6 residents a day — about 89% occupied, or roughly 8 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 4.37 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.57 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.35 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 3.76 hrs/resident/day on weekends vs 4.62 on weekdays — 19% thinner on weekends. RN hours go from 0.68 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 52% 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

8
deficiencies at the latest standard inspection (2025-03-06)
3
at the previous standard inspection (2022-06-13)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

20 citations, most serious first. The 12 most serious are shown; the remaining 8 are one tap away and print in full.

  • Actual harm · G2025-03-06 · 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 medical record review, staff interview, and review of facility policies, the facility failed to ensure pressure ulcer care treatments were initiated timely and wound assessments were thoroughly completed to prevent the worsening of a pressure ulcer. Actual harm occurred to Resident #12 when the resident was readmitted to the facility with a stage II pressure ulcer (partial-thickness skin loss with exposed dermis) on assessment and no treatment orders were implemented until concerns were voiced by the resident's representative several days later. This resulted in Resident #12's pressure ulcer worsening to a stage III pressure ulcer (full-thickness skin loss) and associated deterioration and drainage. This affected one (#12) of three residents reviewed for pressure ulcers. The facility census was 69. Findings included: Review of the medical record for Resident #12 revealed an admission date of 01/30/24 with diagnoses including diabetes mellitus, osteoarthritis, hypothyroidism, hypertension, atrial…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2019-05-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of an incident report, observation, staff interview and policy review, the facility failed to ensure Resident #88's fall interventions were implemented to prevent falls in accordance with the resident's fall risk care plan. This resulted in actual harm when Resident #88's call light was not within reach at the time the resident experienced a fall, the resident was subsequently hospitalized and required surgical intervention for a left hip fracture. In addition, the facility failed to ensure staff implemented a second resident's (#14) fall interventions in accordance with the care plan which did not result in injury. This affected two (#88 and #14) of two residents reviewed for falls and accidents. The facility census was 110. Findings include: 1. Review of Resident #88's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include dementia with Lewy Bodies, dysphagia, hypertension, major depressive disorder and hyperlipidemia. Review of 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-19 · 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 record review, observation, staff interview and review of facility policy,the facility failed to ensure wound treatment orders were completed as ordered. This affected one resident (#12) of three reviewed for wounds. The facility census was 67.Findings include:Review of medical record for Resident #12 revealed admission date of 01/31/25. The resident's medical diagnosis included Chronic Obstructive Pulmonary Disease (COPD), osteoarthritis, Congestive Heart Failure (CHF), anxiety, depression and peripheral autonomic neuropathy. The resident remained in the facility.The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #12 had a Brief Interview Mental Status (BIMS) score of 14 indicating intact cognition. He was independent with eating and dependent upon staff for toileting hygiene, bed mobility and transfers.Review of the physician orders revealed Resident #12 had an order dated 04/29/26 to cleanse the skin tear on the right lower leg with wound cleanser and apply a band aid daily.Observation…

    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 · F2025-09-19 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interviews, employee record review, and policy review, the facility failed to employ a full time Director of Nursing (DON) for the skilled nursing facility. This had the potential to affect all 71 residents in the facility. Findings include: Interview on 09/19/25 with Licensed Practical Nurse (LPN) #448 confirmed the DON is over the skilled nursing and assisted living residents. Interview also confirmed the DON has been over the skilled nursing and assisted living residents for the past two years. Interview on 09/19/25 at 11:56 A.M. with the DON confirmed she has worked as the DON for the skilled nursing facility (SNF) and assisted living facility (ALF) full time since June 2025. Interview also confirmed she addresses concerns on the SNF and the AL as they arise and that she doesn't know how much time she spends on the SNF or the AL each week. Interview on 09/19/25 at 12:35 P.M. with the Licensed Nursing Home Administrator (LNHA) confirmed the DON is over the SNF and AL for the community full time. Interview also confirmed she has never been told the DON could not…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-14 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interviews, review of self-reported incident (SRI), review of witness statements, review of in-service, review of employee file, review of corrective action, and review of policy, the facility failed to protect residents from neglect/physical abuse. This affected one (#1) of three residents reviewed for abuse. The facility census was 67. Findings include: Review of the medical record of Resident #1 revealed an admission date of 05/24/23. Diagnoses include Alzheimer's disease, dementia without behavioral disturbance, and symptoms and signs involving cognitive functions and awareness. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively impaired and required extensive assistance with personal hygiene. Review of the facility investigation revealed a hand-written statement from the Certified…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · D2025-03-06 · 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, a resident representative interview, and staff interview, the facility failed to ensure residents were provided a dignified dining experience when residents were not provided meals timely. This affected three (#19, #47, and #53) of ten residents observed in the 500 Hall dining room. The facility census was 69. Findings included: Observation on 03/05/25 from 11:37 A.M. to 1:13 P.M. revealed, at 11:37 A.M., staff assisted residents to the 500 Hall dining room and started to serve the residents drinks. Observation at 11:58 A.M. revealed 10 residents to be sitting in the dining room. Observation at 12:04 P.M. revealed staff started to serve residents their lunch trays in the dining room and meal trays were delivered to the rooms of the residents who did not come to the dining room for lunch. Observation at 12:35 P.M. revealed three (#19, #47, and #53) residents out of the 10 residents in the dining room had not been served a lunch tray while the other seven residents were actively eating their meals or had finished their meals and were leaving the dining room.…

    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 · D2025-03-06 · 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 — the official record, unedited, may be distressing

    Based on observation, staff interview, and policy review, the facility failed to ensure wheelchairs were maintained in a clean and sanitary manner. This affected one (#1) of five reviewed for wheelchair cleanliness. The facility census was 69. Findings include: Observation on 03/03/25 at 9:58 A.M. revealed Resident #1's wheelchair had a thick coating of food particles on the left side covering the lower rails and the left side of the seat cushion. Observation and interview on 03/04/25 at 2:43 P.M. with Certified Nurse Aide (CNA) #491 verified the appearance of Resident #1's wheelchair during the observation. CNA #491 stated it was the responsibility of the third shift CNAs to clean resident wheelchairs. Interview on 03/04/25 at 3:00 P.M. with Chief Clinical Officer #505 provided additional verification of the appearance of Resident #1's wheelchair. Review of the undated policy titled, Cleaning and Disinfection of Resident-Care Equipment, revealed resident-care equipment will be cleaned.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-06 · 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 medical record review, resident representative interview, staff interview, and policy review, the facility failed to ensure care conferences were completed as required. This affected one (#32) of one residents reviewed for care conferences. The facility census was 69. Findings included: Review of the medical record for Resident #32 revealed an admission date of 06/03/24 with diagnoses of dementia, osteoarthritis, congestive heart failure, and chronic kidney disease stage III. Review of Resident #32's Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #32 had severely impaired cognition and required partial/moderate staff assistance with toilet hygiene, bed mobility, transfers and substantial/maximum assistance with bathing. Review of the medical record for Resident #32 revealed no documentation to support the facility conducted a care conference since the initial care conference in June 2024. Interview on 03/03/25 at 3:23 P.M. with Resident #32's representative stated the facility had not…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-06 · 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 medical record review, staff interviews, and policy review, the facility failed to ensure pharmacy recommendations were reviewed by the physician and failed to ensure physician responses to pharmacy recommendations were accurate. This affected two (#11 and #31) of the five residents reviewed for medications. The facility census was 69. Findings included: 1. Review of the medical record for Resident #11 revealed an admission date of 09/05/23 with diagnoses of dementia, Parkinson's disease, asthma, chronic obstructive pulmonary disease (COPD), depression, and anxiety. Review of Resident #11's quarterly Minimum Data Set (MDS) assessment, dated 02/14/25, revealed the resident had severe cognitive impairment, required partial/moderate staff assistance with bathing and bed mobility, substantial/maximum assistance with toilet hygiene and transfers and received antipsychotic and antidepressant medications. Review of Resident #11's physician orders revealed an order dated 09/06/23 for the antidepressant…

    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 · D2025-03-06 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review and staff interview, the facility failed to ensure recommendations for gradual dose reductions of psychotropic medications were attempted or completed as required. This affected one (#11) of five residents reviewed for medications. The facility census was 69. Findings included: Review of the medical record for Resident #11 revealed an admission date of 09/05/23 with diagnoses of dementia, Parkinson's disease, asthma, chronic obstructive pulmonary disease (COPD), depression, and anxiety. Review of Resident #11's quarterly Minimum Data Set (MDS) assessment, dated 02/14/25, revealed the resident had severe cognitive impairment, required partial/moderate staff assistance with bathing and bed mobility, substantial/maximum assistance with toilet hygiene and transfers, and received antipsychotic and antidepressant medications. Review of the medical record for Resident #11 revealed a physician order dated 09/06/23 for the antidepressant medication duloxetine 60 milligrams (mg) one tablet by mouth every bedtime. Review of the medical record for Resident #11…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-06 · tag F0825 — isolated
    Provide or get specialized rehabilitative services as required for a 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, staff and resident interview, nurse practitioner interview, and medical record review, the facility failed to ensure residents received specialized rehabilitative services as determined by their comprehensive plan of care to assist them to attain, maintain or restore, their highest practicable level of physical, mental, functional and psycho-social well-being. This affected one (#28) of two residents reviewed for activities of daily living. The census was 69. Findings include: Review of the medical record for Resident #28 revealed an admission date of 10/20/23. Diagnoses included hemiplegia following a stroke affecting the left dominant side, depression, type two diabetes mellitus, and congestive heart failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 was cognitively intact, required assistance with eating, and was dependent for toileting hygiene, bed mobility, and transfers. Review of Resident #28's care plan revealed the resident was at…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-06 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) website, the facility failed to ensure residents on infection control precautions had appropriate signage posted, failed to ensure adequate personal protective equipment (PPE) was worn for care provided to residents on infection control precautions, and failed to ensure PPE was properly disposed of after use. This affected three (#12, #38, and #179) of three residents reviewed for infection control precautions. The facility census was 69. Findings include: 1. Review of the medical record for Resident #179 revealed an admission date of 02/28/25. The resident was admitted with diagnoses including atrial fibrillation, herpes simplex virus (HSV-1), and right hip dislocation. Review of Resident #179's physician orders revealed the resident was ordered contact isolation for a diagnosis of Clostridium difficile (C. diff) with a start date of 02/28/25 and end date 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 8 citations
  • Potential for harm · D2024-06-18 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility self-reported incidents (SRI's), staff interviews, and review of the facility policy, the facility failed to conduct a thorough neglect investigation. This affected one (#44) of three residents reviewed for neglect. The facility census was 76. Findings include: Review of the medical record revealed Resident #44 was admitted to the facility on [DATE] with diagnoses of cerebral infarction, acute cystitis with hematuria, repeated falls, congestive obstructive pulmonary disease, mitral valve prolapse, atrial fibrillation, depression and anxiety. Review of the Significant Change Minimum Data Set (MDS) dated [DATE] revealed Resident #44 was cognitively intact, had an indwelling Foley catheter (discontinued 05/03/24), was frequently incontinent of bowel and had no Range of Motion impairment in upper and lower extremities. Resident #44 required moderate assistance with eating and oral hygiene, maximal assistance with personal hygiene and bed mobility, and dependent for…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2022-06-13 · tag F0888 — widespread
    Ensure staff are vaccinated for COVID-19
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of Centers for Medicare and Medicaid Services (CMS) memorandum QSO-22-09-ALL, review of the COVID-19 staff vaccination status, review of staffing schedules, review of the list of COVID positive resident, staff interview, and review of the facility policy; the facility failed to ensure the staff COVID-19 vaccination rate was 100%. This had the potential to affect all 63 residents who resided in the facility. The census was 63. Findings include: Review of the undated facility COVID-19 staff vaccination status revealed the facility had a total of 160 employees. There were 117 employees fully vaccinated for COVID-19, 41 employees with exemptions and two employees who were not vaccinated for COVID-19 and did not have an exemption. The staff vaccination rate was 98.8 percent. Review of the list of partially vaccinated staff revealed that Licensed Practical Nurse (LPN) #114 and Dietary Aide #256 received only one dose of a two-dose vaccine. Review of the facility's undated list of COVID positive residents revealed there had not been any residents diagnosed with COVID-19 in…

    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 · D2022-06-13 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably 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, interview and policy review, the facility failed to ensure a resident had his call light within reach while sitting in his recliner. This affected one (Resident #19) of twenty four residents observed on the initial pool. The census was 63. Finding include: Review of the medical record for Resident #19 revealed an admission date of 02/10/21. Diagnoses included malignant neoplasm of prostate, insomnia, malignant neoplasm bone and dementia. Review of the Minimum Data Set, dated [DATE] revealed Resident #19 was severely cognitively impaired. Review of the care plan for Resident #19 revealed a plan of care for being at risk for falls, he is non ambulatory and has a history of falls with a goal of he will not experience serious injury from fall with interventions which included to keep call light within easy reach and encourage resident to use call light for assistance. During observation on 06/06/22 at 10:28 A.M., Resident #19 was in his recliner in his room without a call light near him. 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
  • Potential for harm · D2022-06-13 · tag F0812 — failed to store, cook, and serve food safely — isolated
    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, interview and policy review, the facility failed to ensure staff used gloves and performed hand washing as appropriate. This affected 13 (Residents #3, #6, #9, #10, #12, #19, #23, #25, #32, #39, #40, #255, and #256) of 13 residents who receive meals on the fifth floor. The census was 63. Finds include: During observation of meal service on the fifth floor on 06/08/22 at 11:45 A.M., Dietary Aide #254 cleaned his hands and put on gloves. He started serving meals. Without removing his gloves, he went out to the dining room, retrieved items from the refrigerator and got coffee and other drinks for residents. He came back into the serving area. He did not change his gloves or wash his hands after reentering the serving area. During interview at the time of the observation, Dietary Aide #254 stated he puts gloves on and they are on for the duration of meal service. He does not touch the food. He goes to the dumbwaiter when the special foods come up, or helping out the staff with delivering drinks in between plating food. During interview on on 06/08/22 at 12:30 P.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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-05-16 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal 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 medical record review and staff interview, the facility failed to notify the resident/resident representative in writing of a transfer/discharge to the hospital. This affected one (#104) of four resident records reviewed for hospitalization. The census was 110. Findings include: Review of the medical record for Resident #104 revealed the resident was admitted to the facility on [DATE]. Diagnoses include diabetes, end stage renal disease, dependent on renal dialysis, anemia, coronary artery disease, and hypertension. Review of a progress note dated 03/01/19 at 12:53 P.M. revealed Resident #104's blood glucose level dropped while at a scheduled vascular center appointment. The resident was sent from the vascular center to the hospital for evaluation and treatment. Review of a progress note dated 03/01/19 at 4:40 P.M. revealed the resident was admitted to the hospital for low blood sugar. Documentation revealed the resident returned to the facility on [DATE]. Continued review of the progress notes revealed…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-05-16 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    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 notify the resident/resident representative of the facility's bed hold policy when a resident was transferred to the hospital. This affected one (#104) of four resident records reviewed for hospitalization. The census was 110. Findings include: Review of the medical record for Resident #104 revealed the resident was admitted to the facility on [DATE]. Diagnoses include diabetes, end stage renal disease, dependent on renal dialysis, anemia, coronary artery disease, and hypertension. Review of a progress note dated 03/01/19 at 12:53 P.M. revealed Resident #104's blood glucose level dropped while at a scheduled vascular center appointment. The resident was sent from the vascular center to the hospital for evaluation and treatment. Review of a progress note dated 03/01/19 at 4:40 P.M. revealed the resident was admitted to the hospital for low blood sugar. Documentation revealed the resident returned to the facility on [DATE]. Continued review…

    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 · D2019-05-16 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    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, observations and staff and resident interview, the facility failed to provide an individualized activity program designed to meet the interests and total care needs of Resident #61. This affected one (#61) out of two residents reviewed for activities. The facility census was 110. Findings include: Review of Resident #61's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include cerebral palsy, aphasia, mix receptive expressive language, dysphagia oropharyngeal phase, hypertension, obesity, conduct disorder, cataract, contracture joint, abnormal posture, contracture: right hand, left hand, left elbow, right elbow, right knee, left ankle, right ankle, and heart failure, stiffness right shoulder neck and left should neck. Review of Resident #61's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident prefers listening to music, being around animals such as pets, doing things with groups of people, participating in favorite…

    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 before2019-05-16 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations and staff interview, the facility failed to ensure one resident's bruise was documented in the medical record and monitored for changes affecting one (#44) out of four residents reviewed for non-pressure skin issues. Additionally, the facility failed to monitor a residents weights and input/output as ordered by the physician regarding a residents cardiac status affecting one (#1) out of 22 residents reviewed for appropriate care and services. The facility census was 110. Findings include: 1. Review of Resident # 44's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include type two diabetes mellitus, hypothyroidism and dementia without behavioral disturbance. The resident's minimum data set (MDS) assessment dated [DATE] indicated the resident was severely cognitively impaired and required extensive assistance with activities of daily living (ADL's) including bed mobility, transferring, dressing, eating, toilet use and personal…

    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

“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 2025-04-02 for 22 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleSince
FIFTH THIRD BANK, NATIONAL ASSOCIATIONOrganization5% OR GREATER MORTGAGE INTERESTsince 09/01/2010
ALLREAD, KARAIndividualW-2 MANAGING EMPLOYEEsince 03/30/2010
EUBANK, CARLIndividualW-2 MANAGING EMPLOYEEsince 03/30/2010
GASPER, LISAIndividualW-2 MANAGING EMPLOYEEsince 03/30/2010
HILL, HOLLYIndividualW-2 MANAGING EMPLOYEEsince 03/30/2010
JAROS, FRANKIndividualW-2 MANAGING EMPLOYEEsince 03/30/2010
KEEN, JAMIIndividualW-2 MANAGING EMPLOYEEsince 12/01/2021
NEFF, PAMELAIndividualW-2 MANAGING EMPLOYEEsince 03/30/2010
OVERFIELD, MELODYIndividualW-2 MANAGING EMPLOYEEsince 03/30/2010
RANDOLPH, MICHAELIndividualW-2 MANAGING EMPLOYEEsince 03/30/2010
WARNER, JOHNIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICERsince 07/01/2007
ARNOLD, MATTHEWIndividualCORPORATE DIRECTORsince 01/01/2010
KELLER, JOHNIndividualCORPORATE DIRECTORsince 01/01/2011
KEPLER, DAVIDIndividualCORPORATE DIRECTORsince 01/01/2012
RIESSER, LAWRENCEIndividualCORPORATE DIRECTORsince 01/01/2011

CMS files one row per role, so the 16 rows in the source record cover these 15 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

1 organizational owner 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.

$17.3M
Net patient revenuemost recent cost report
-34.7%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 45%Medicare 12%Other / private 43%

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

$987per resident / day
operating cost
$30,000per month
≈ monthly operating cost
$733per 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 365014. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-06, 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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