Bradford Place Care Center
1302 Millville Avenue, Hamilton, OH 45013 · For profit - Limited Liability company · 79 certified beds · (513) 867-4101 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 Apr 2026
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has citations for mishandling residents’ money or property (F0565, F0568, F0569)
- it has 1 actual-harm citation
- 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
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- nursing-staff turnover (60%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 4 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, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 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 3 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.
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 | 13.7% | 5.3% | 15.4% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 10.3% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.2% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.8% | 0.4% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 13.5% | 30.1% | 6.5% | better 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 | 2.7% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 10.4% | 6.1% | 16.1% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 14.7% | 25.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 73.6% | 94.5% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 2.6% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 22.3% | 21.4% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 4.6% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 3.4% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 87.5% | 75.6% | 79.4% | 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.
47.1% 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 29 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.35 therapist hours per resident per day in 2026Q1 — more than 59% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 2% 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
| 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 | 47.1%CMS range 30.6–62.1 | 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 | 11.8%CMS range 6.8–17.1 | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 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 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 | 1.09 | 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 79 beds and averages 62.7 residents a day — about 79% occupied, or roughly 16 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.23 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.82 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.06 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 3.72 hrs/resident/day on weekends vs 4.44 on weekdays — 16% thinner on weekends. RN hours go from 0.92 to 0.57 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 60% is well above 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 more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
31 citations, most serious first. The 11 most serious are shown; the remaining 20 are one tap away and print in full.
- Actual harm · G2025-11-25 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observations, staff interviews, and policy review, the facility failed to ensure Resident #19 received prompt dental care services. This resulted in Actual Harm when Resident #19, who had persistent dental pain, developed a dental infection and had significant weight loss. On 06/19/25 at 6:50 P.M., Resident #19, who was nonverbal, screamed loudly for most of the shift due to dental pain and was unable to be redirected. On 06/20/25, Resident #19 ' s oral intake decreased related to ongoing dental pain. Resident #19 was seen by the nursing staff on 06/25/25 for continued behaviors including a decrease in oral intake, biting on her fingers, and was suspected of having a dental infection. Resident #19 was started on Augmentin, an antibiotic, related to a tooth infection. On 07/07/25, Resident #19 continued to have behaviors and had lost weight due to not eating related to dental pain. On 07/15/25, Resident #19 continued to have documented weight loss from decreased oral intake related to dental pain and a dental consultation was ordered. The consult was 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.
- Potential for harm · E2026-04-24 · tag F0568 — patternProperly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, review of resident fund accounts, staff interview and review of the facility policy, the facility failed to maintain resident funds accounts using basic accounting principles and failed to ensure residents received a copy of their resident funds account quarterly statements. This affected six (Residents #2, #4, #27, #32, #47 and #62) of seven residents reviewed for resident funds accounts. The facility census was 66 residents. Findings include: 1.Review of the medical record for Resident #2 revealed an admission date of 05/23/25 with diagnoses of congestive heart failure, Alzheimer's disease, and aphasia. Review of the Minimum Data Set (MDS) assessment for Resident #2 dated 03/05/26 revealed the resident was severely cognitively impaired and required staff assistance with activities of daily living (ADLs.) Review of the quarterly resident funds statement for Resident #2 dated 01/01/26 to 03/31/26 revealed the resident had a beginning balance of $2270.97 and an ending balance of $1888.16. There was a debit for a purchase from an online retailer 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 · E2026-04-24 · tag F0569 — patternNotify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, review of resident funds accounts, and staff interview, the facility failed to notify residents that received Medicaid benefits or their representatives when the amount in the resident's resident funds account reached $200 less than the supplemental security income (SSI) resource limit. This affected six (Residents #2, #4, #27, #32, #47 and #62) of seven residents reviewed for resident funds accounts. The facility census was 66 residents.Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 05/23/25 with diagnoses of congestive heart failure, Alzheimer's disease, and aphasia. Resident #2's payor source was Medicaid. Review of the Minimum Data Set (MDS) assessment for Resident #2 dated 03/05/26 revealed the resident was severely cognitively impaired and required staff assistance with activities of daily living (ADLs.) Review of the quarterly resident funds statement for Resident #2 dated 01/01/26 to 03/31/26 revealed the resident had a beginning balance of $2270.97 and an ending balance of $1888.16. There was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-04-24 · tag F0602 — failed to protect residents from theft of their belongings — patternProtect 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
Based on medical record review, review of resident fund account records, ,staff interview, review of facility self-reported incidents (SRIs), and review of the facility policy, the facility failed to ensure money was not misappropriated from resident funds accounts and items were not purchased using resident funds without authorization. This affected five (Resident #2, #4, #27, #32, and #62) of seven residents reviewed for misappropriation of resident funds. The facility census was 66 residents. Findings include: 1.Review of the medical record for Resident #2 revealed an admission date of 05/23/25 with diagnoses of congestive heart failure, Alzheimer's disease, and aphasia. Review of the Minimum Data Set (MDS) assessment for Resident #2 dated 03/05/26 revealed the resident was severely cognitively impaired and required staff assistance with activities of daily living (ADLs.) Review of the quarterly resident funds statement for Resident #2 dated 01/01/26 to 03/31/26 revealed the resident had a beginning balance of $2270.97 and an ending balance of $1888.16. There was a debit for a…
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 · E2026-04-24 · tag F0609 — failed to report abuse allegations — patternTimely 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
Based on medical record review, review of resident fund accounts, resident interview, staff interview, review of facility Self-Reported Incidents (SRIs), and review of the facility policy, the facility failed to timely report allegations of misappropriation of resident funds. This affected five (Residents #2, #0, #27, #32, and #62) of seven residents reviewed for misappropriation of resident funds. The facility census was 66 residents.Findings include: 1.Review of the medical record for Resident #2 revealed an admission date of 05/23/25 with diagnoses of congestive heart failure, Alzheimer's disease, and aphasia. Review of the Minimum Data Set (MDS) assessment for Resident #2 dated 03/05/26 revealed the resident was severely cognitively impaired and required staff assistance with activities of daily living (ADLs.) Review of the quarterly resident funds statement for Resident #2 dated 01/01/26 to 03/31/26 revealed the resident had a beginning balance of $2270.97 and an ending balance of $1888.16. There was a debit for a purchase from an online retailer of $62.21 on 01/29/26 and a…
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 · E2026-04-24 · tag F0610 — failed to investigate and act on abuse reports — patternRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, review of resident fund accounts, review of facility self-reported incidents (SRIs), staff interview, resident interview, review of employee records, and review of the facility policy, the facility failed to thoroughly investigate allegations of misappropriation including investigating thoroughly investigating all alleged perpetrators. This affected five (Residents #2, #4, #27, #32, and #62) of seven residents reviewed for misappropriation of resident funds. The facility census was 66 residents. Findings include: 1.Review of the medical record for Resident #2 revealed an admission date of 05/23/25 with diagnoses of congestive heart failure, Alzheimer's disease, and aphasia. Review of the Minimum Data Set (MDS) assessment for Resident #2 dated 03/05/26 revealed the resident was severely cognitively impaired and required staff assistance with activities of daily living (ADLs.) Review of the quarterly resident funds statement for Resident #2 dated 01/01/26 to 03/31/26 revealed the resident had a beginning balance of $2270.97 and an ending balance 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 · D2026-04-24 · 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
Based on medical record review, review of emergency medical services (EMS) run report, staff interview, EMS interview, and review of the facility policy, the facility failed to ensure resident do not resuscitate comfort care (DNRCC) orders were implemented appropriately. This affected one (Resident #67) of two residents reviewed for advanced directives. The facility census was 66 residents.Findings include: Review of the medical record for Resident #67 revealed an admission date of 02/27/26 with diagnoses including chronic obstructive pulmonary disease, peripheral vascular disease, type two diabetes mellitus, and encephalopathy and a discharge date of 04/12/26. Review of the physician's orders for Resident #67 revealed an order dated 03/02/26 indicating the resident's code status was do not resuscitate comfort care (DNRCC). Review of the medical record for Resident #67 revealed it did not include a DNRCC form Review of the Minimum Data Set (MDS) assessment for Resident #67 dated 03/05/26 revealed the resident was cognitively intact and required assistance with activities of daily…
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 · F2025-11-25 · tag F0804 — failed to serve food at safe, palatable temperature — widespreadEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure food was served in an appetizing manner. This affected two (Residents #86 and #16) and had the potential to affect all of the residents residing in the facility. The facility census was 75 residents. Findings include: Observation on 09/23/25 at 12:15 P.M. of a test tray revealed there were two tacos wrapped in foil with liquid pooled up underneath the plate. There was a significant amount of liquid contained within the foil and the tortilla of the taco was saturated with liquid. Interview on 09/23/25 at 12:16 P.M. with District Manager (DM) #600 verified there was liquid in the foil which altered the texture of the tortillas. Observation on 09/23/25 at 12:25 P.M. revealed Resident #86 attempted to eat the tacos on his lunch tray. The tortillas were wet and soggy and the resident had difficulty eating the tacos.Interview on 09/23/25 on 12:26 P.M. with Resident #86 confirmed the taco tortillas were wet and soggy and he could not eat them.Interview on 09/23/25 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.
- Potential for harm · F2025-11-25 · tag F0807 — failed to offer suitable drinks — widespreadEnsure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure beverage preferences and requests were honored. This affected one (Resident #16) of one residents reviewed for food preferences and had the potential to affect all of the residents residing in the facility. The facility census was 75 residents.Findings include: Observation on 09/22/25 at 11:46 A.M. revealed Certified Nursing Assistant (CNA) #525 entered Resident #16's room to deliver a lunch tray. Resident #16 asked CNA #525 for milk. CNA #525 stated there was no milk in the refrigerator, but otherwise she would give it to him. Interview on 09/22/25 at 11:47 A.M. with CNA #525 verified Resident #16 asked for milk and she told him it was not available. CNA #525 confirmed she did not go look for the milk or call the kitchen for the milk and further stated if the resident was supposed to have it, it would have been on his tray. Interview on 09/23/25 at 3:24 P.M. with Resident #16 verified he did not get the milk he requested at lunch the day prior. Resident #16…
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 before2025-11-25 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure food was prepared, served and stored in a manner to protect against the potential spread of foodborne illness. This affected one (Resident #10) and had the potential to affect all of the residents residing in the facility. The facility census was 75 residents. Findings include: Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure food was prepared, served and stored in a manner to protect against the potential spread of foodborne illness. This affected one (Resident #10) and had the potential to affect all of the residents residing in the facility. The facility census was 75 residents. Findings include: 1.Observation on 09/23/25 at 11:50 A.M. revealed [NAME] #701 prepared trays for the lunch meal on tray line. [NAME] #701 placed a scoop of cooked peppers and onions onto a plate. [NAME] #701 used his bare fingers to pick up a piece of onion which was hanging over the edge of the plate…
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 · E2025-11-25 · tag F0565 — failed to support the resident council — patternHonor the resident's right to organize and participate in resident/family groups in the facility.
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 staff interviews, record review, and review of the Resident Council meeting minutes, the facility failed to respond and address resident concerns expressed in the Resident Council meetings. This affected five (#56, #14, #44, #39 and #67) of the five residents interviewed during Resident Council meeting. The facility total census was 75.Findings included: Record Review of Resident #56 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #56 include anemia. Review of the Minimum Data Set (MDS) comprehensive assessment for Resident #56 dated 07/02/25, revealed the resident had intact cognition.Record review of Resident #14 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #14 Alzheimer's disease. Review of the MDS comprehensive assessment for Resident #14 dated 09/10/25, revealed the resident had moderately impaired cognition.Record review of Resident #44 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident…
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 · E2025-11-25 · tag F0657 — failed to keep the care plan current — patternDevelop 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, care conference summary report review, care plan review, staff interview, and policy review, the facility failed to ensure care conferences were provided on a quarterly basis with the Resident and/or Representative and failed to ensure care plans were updated timely. This affected five (#30, #07, #06, #03, and #55) of the eight residents reviewed for care plans. The facility also failed to ensure care plans were updated timely when a change in condition occurred. This affected two (#19 and #45) of the eight residents reviewed for care plans. The facility census was 75.Findings included: 1) Review of the medical record revealed Resident #30 was admitted to the facility on [DATE]. Diagnoses included chronic respiratory failure with hypoxia, chronic obstructive pulmonary diseases, congestive heart failure, hypertension, sleep apnea, and morbid obesity. Review of the Minimum Data Set (MDS) Medicare-Five Day assessment dated [DATE] revealed Resident #30 had intact cognition. Review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-11-25 · 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
Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure medications were administered in a sanitary manner. This affected one (Resident #19) of four residents observed for medication administration. Based on medical record review, observation, and staff interview, the facility failed to follow physician ordered transmission-based precautions. This affected three (Residents #19, # 85, #81) of four residents reviewed for transmission-based precautions. Based on observation and staff interview, the facility also failed to ensure staff practiced appropriate hand hygiene during delivery of meal trays. This affected three (Residents #31, #65 and #86) and had the potential to affect all of the residents residing in the facility. The facility census was 75 residents. Findings include: 1. Review of the medical record for Resident #39 revealed an admission date of 07/19/22 with diagnoses including chronic obstructive pulmonary disease, atrial fibrillation, congestive heart failure and diabetes mellitus type two. Review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-25 · 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, family interview, and policy review, the facility failed to ensure responsible parties and/or physicians were notified of significant weight loss. This affected three (#45, #61 and #19) of the three residents reviewed for nutrition. The facility census was 75.Findings included: 1) Review of the medical record of Resident #45 revealed an admission date of 02/16/23. Diagnoses included type two diabetes mellitus, depression, Alzheimer's disease with behavioral disturbance, depression, anxiety, hypertension, Review of the quarterly Minimum Data Set (MDS) assessment for Resident #45 dated 07/10/25, revealed the resident had severely impaired cognition. The resident was independent or required set-up or supervision for all activities of daily living (ADLs). The resident weighed 177 pounds and had a significant non-prescribed weight loss. Review of Resident #45's weights revealed the following: a) On 01/08/25, the resident weighed 190.8 pounds (lb).b) On 02/01/25, 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 · D2025-11-25 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the Ombudsman's Office after residents were discharged to the hospital. This affected three residents (#02, #64 and #19) of the four residents reviewed for hospital discharge. The facility census was 75.Findings include:1) Record review of Resident #02 revealed the resident was admitted to the facility on [DATE]. The resident was discharged to the hospital from [DATE] to 07/04/25 and 07/09/25 to 07/11/25. Diagnoses for Resident # 2 included surgical after care of 07/04/25, dementia, diabetes, osteoarthritis of left hip, peripheral vascular disease, and heart failure.Review of the Minimum Data Set, (MDS) comprehensive assessment for Resident #02 dated 08/08/25, revealed the resident had intact cognition.2) Record review of Resident #64 revealed the resident was admitted to the facility on [DATE]. The resident was discharged to the hospital from [DATE] to 07/03/25 and 07/31/25 to 08/05/25. Diagnoses for Resident #64 include metabolic…
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 before2025-11-25 · 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 medical record review, observation, resident interview, staff interview, and policy review, the facility failed to provide needed personal care for three (#07, #41 and #55) of the three residents reviewed for personal care. The facility census was 75.Findings included:1) Review of the medical record revealed Resident #07 was admitted to the facility on [DATE]. Diagnoses included end stage renal disease (ESRD) with dependence on hemodialysis, diabetes mellitus type II, cerebral infarction with aphasia and hemiplegia (left non-dominant side).Review of Plan of Care for Resident #07 dated 04/20/22, revealed Resident #07 required assistance with activities of daily living (ADLs) related to debility, decreased mobility, self-care deficit related to diagnoses including, but not limited to, cerebral vascular accident (CVA) sequelae with left side hemiplegia/paresis, end stage renal disease with hemodialysis, seizure disorder, encephalopathy, and diabetes mellitus type II, with an intervention of nail care as…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-25 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, staff interview, and review of the facility policy, the facility failed provide tube feedings as ordered. This affected one (Resident #19) of four residents reviewed for unplanned weight loss. The facility census was 75 residents.Findings include:Review of the medical record for Resident #19 revealed an admission date of 03/14/24 with diagnoses including vascular dementia, type two diabetes mellitus, major depressive disorder, and epilepsy. Review of the Minimum Data Set (MDS) assessment for Resident #19 dated 07/23/25 revealed the resident had severe cognitive impairment, required partial assistance with eating, had a five percent or greater weight loss during the review period, and received a mechanically altered diet supplemented with tube feedings. Review of the physician's orders for Resident #19 revealed order dated 08/28/25 for the resident to receive a supplemental feeding via gastrostomy tube (g-tube) of Jevity 1.5 Cal, 237 milliliters if the resident's meal consumption was less than 75 percent (%). Review of the Medication Administration…
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 · D2025-11-25 · 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
Based on medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to administer medications as ordered by the physician. This affected one (Resident #08) of four residents reviewed for medication administration. The facility census was 75 residents. Findings include: Review of the medical record for Resident #08 revealed an admission date of 10/14/22 with diagnoses including thoracic, thoracolumbar and lumbosacral intervertebral disc disorder, acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease and hypertension.Review of the Minimum Data Set (MDS) assessment for Resident #08 dated 08/20/25 revealed the resident had intact cognition and required staff assistance with activities of daily living (ADLs.) Review of the physician ' s orders for Resident #08 revealed an order dated 09/02/25 for Ambien five milligrams (mg) give one-half tablet by mouth at bedtime Review of the controlled drug receipt/record disposition form for Resident #08 ' s Ambien revealed the medication was not signed out…
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 · D2025-11-25 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure residents were offered pneumococcal vaccines as required. This affected one (Resident #19) of five residents reviewed for immunizations. The facility census was 75 residents. Findings include:Review of the medical record for Resident #19 revealed an admission date of 03/14/24 with diagnoses including vascular dementia, type two diabetes mellitus, major depressive disorder, and epilepsy. Review of the Minimum Data Set (MDS) assessment for Resident #19 dated 07/23/25 revealed the resident had severe cognitive impairment and required assistance from staff with activities of daily living (ADLs.) Review of the medical record for Resident #19 revealed it did not include documentation of the facility offering the resident and/or reaching out to the resident's representative regarding consent for a pneumococcal vaccination. Interview on 09/29/25 at 11:23 A.M. with the Director of Nursing (DON) confirmed the medical record for Resident #19 did not include documentation 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.
- Potential for harm · D2024-05-21 · tag F0624 — isolatedPrepare residents for a safe transfer or discharge from the nursing home.
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 the emergency medical services (EMS) run report, review of the hospital record review, staff interviews and policy review, the facility failed to ensure a resident was adequately prepared for a transfer by ensuring EMS and the hospital was provided with the resident's code status and other pertinent information. This affected one (#100) of three residents reviewed for hospitalization. Facility census was 70. Findings include: Review of the medical record of Resident #100 revealed an admission date of 10/08/20. The resident transferred to the hospital on [DATE] and did not return to the facility. Diagnoses included spinal stenosis, type 2 diabetes mellitus, Alzheimer disease, dementia with mood disturbance, major depressive disorder, anxiety disorder, hyperlipidemia, and hypertension. Review of Resident #100's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of the medical record revealed a Change 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 · D2024-03-06 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide 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 policy review, the facility failed to assess and implement a physician ordered treatment for a resident admitted with a pressure ulcer to the coccyx. This affected one (#72) of three residents reviewed for pressure ulcer care. Facility census was 71. Findings Include: Record review revealed Resident #72 was admitted to the facility on [DATE] with diagnoses including diabetes, heart failure, Parkinson's, malnutrition and Stage IV (full thickness tissue loss with exposed bone, tendon or muscle, slough or eschar may be present on some parts of the wound bed, including undermining and tunneling) pressure ulcer to the coccyx. Resident #72 was discharged on 02/03/24. Record review revealed there was no comprehensive Minimum Data Set (MDS) completed for Resident #72 due to the residents short stay at the facility. Additionally, there was no documentation of a Braden Scale being completed for Resident #72. Review of Resident #72 base line plan of care initiated…
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 · D2023-11-01 · 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
THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of facility investigation, staff interviews and review of facility policy, the facility failed to ensure a resident was provided dignity and respect. This affected one (#62) of four residents reviewed for dignity and respect. The facility census was 65. Findings include: Review of the medical record for Resident #62 revealed and admission date of 08/01/23. Diagnoses included cerebral infarction (stroke), type II diabetes, Chronic Obstructive Pulmonary Disease (COPD), Alzheimer's disease, emotional lability, depression, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/18/23, revealed Resident #62 had severely impaired cognition. The resident required extensive assistance of one to two staff for bed mobility, transfers, and ambulation. Review of behavior and mood revealed Resident #62 had a behavior of yelling out, cursing, and crying. Review of the plan of care dated 10/18/23 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 · Dcited before2022-12-29 · 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
Based on record review, observations and resident and staff interviews, the facility failed to provide activities of daily living (ADL) assistance to dependent residents. This affected one (#1) of three residents reviewed for ADL's. The census was 65. Findings include: Medical record review for Resident #1 revealed an admission dated on 10/31/19 with diagnoses including but not limited to cerebrovascular disease, schizoaffective disorder bipolar type, hemiplegia affecting left side, bipolar episode depressed mild to moderate severity, hypertension, contracture's, vascular dementia, vitamin D deficiency, hypokalemia, major depressive disorder, anxiety disorder, conversion disorder with seizures, pseudobulbar affect, atopic dermatitis, dysarthria and aphasia following cerebral infarction. Review of the comprehensive Minimum Data Set (MDS) assessment for Resident #1 dated 10/22/22 revealed the resident had intact cognition. Resident #1 was coded with behaviors not directed towards others occurred one to three days during the look back period, with behaviors significantly disrupting…
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 before2022-12-29 · 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 medical record review, observation, staff interview and policy review, the facility failed to ensure prescribed medications were stored securely. This affected two (#1 and #38) randomly observed residents with medications left unattended/unsecured in the residents room. The facility census was 65. Findings include: 1. Review of the medical record for Resident #1 revealed an admission dated on 10/31/19 with diagnoses including but not limited to cerebrovascular disease, schizoaffective disorder bipolar type, insomnia, abnormal posture, hemiplegia affecting left side, bipolar episode depressed mild to moderate severity, hypertension, contracture's, vascular dementia, major depressive disorder, anxiety disorder, conversion disorder with seizures, pseudobulbar affect, dysarthria and aphasia following cerebral infarction. Review of the comprehensive Minimum Data Set (MDS) assessment for Resident #1 dated 10/22/22 revealed the resident had intact cognition. Resident #1 required extensive assist of two staff members for bed mobility, total assist for transfers and toileting with…
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 before2022-12-29 · tag F0880 — failed to prevent and control infections — isolatedProvide 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, observations, resident and staff interviews, and facility policy review, the facility failed to ensure used sharps i.e. needles were disposed of properly. This affected one (#16) of four residents reviewed for sanitary environment. The facility census was 65. Findings include: Medical record review for Resident #16 revealed an admission on [DATE]. Diagnoses include type 2 diabetes without complication, hyperlipidemia, candidiasis of skin and nail, cutaneous abscess of head, localized edema, spondylosis without myelopathy, history of Coronavirus Disease 2019 (COVID-19), hypertension, heart failure, peripheral vascular disease, dementia, urinary tract infection, abnormal posture, neuromuscular dysfunction of bladder and acidosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #16 revealed the resident had impaired cognition. Resident #16 requires supervision for bed mobility, transfers, eating and toileting. Review of the plan of care 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 · Fcited before2019-10-24 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, and policy and procedure review, the facility failed to label and date items in the freezer. The facility also failed to keep daily temperatures in the refrigerator on the third floor and failed to keep the freezer clean. This had the potential to affect all 61 residents residing in the facility. Findings include: On 10/21/19 from 9:10 A.M. to 9:30 A.M., an initial tour of the kitchen was conducted with Registered Dietician (RD) #200. During the observation the following concerns were observed, and all concerns were verified by RD #200. In the freezer, there was a box of chicken strips, a pepperoni pizza, a bag of vegetables, a bag of peas and a box of fish sticks that were unsealed and no opened date. Observation on 10/22/19 at 10:29 A.M. on the third floor revealed the refrigerator's last recorded temperature was dated on 10/20/19. The freezer was dirty and filled with blue and red stains throughout the freezer. Interview on 10/22/19 at 10:33 A.M. with Licensed Practical Nurse (LPN) #57 and State Tested Nursing Assistant (STNA) #103 reported…
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 before2019-10-24 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 observation, resident and staff interview, record review, review of drug manufacturer instructions, and facility Self Administering Medications Policy, the facility failed to store medications securely, dispose of expired medications, and properly label medications. This affected two of fours medication carts. This affected five residents (#20, #27, #43, #54 and #59) on the four north medication cart. The facility identified one resident prescribed insulin and five residents prescribed inhalers on the four north medication cart. The facility census was 61. Findings include: 1. Observation on 10/21/19 at 2:53 P.M. revealed Resident #27 had the following eye medications: two bottles of Dorzolamide Timolol maleate ophthalmic solution 22.3 milligrams (mg.)/6.8 mg per milliliter (ml.), one bottle of Brimonidine tartrate ophthalmic solution 0.2 percent (%), one bottle of prednisolone acetate one %, one bottle of Xalatan 0.005 %, and one tube of neomycin polymyxin b sulfates and Dexamethasone ointment 3.5 grams located on the residents tray table and in the unlocked cabinet beside…
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 · D2019-10-24 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — the official record, unedited, may be distressing
Based on staff interview and medical record review, the facility failed to ensure Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) was provided when skilled services ended and the resident remained at the facility. This affected one (Resident #48) of three residents reviewed for Beneficiary Protection Notification. The facility census was 61. Findings include: Medical record review revealed Resident #48 was informed on 09/09/19, skilled services would end on 09/11/19. Resident #48 remained at the facility and there wasn't any evidence in the medical record that Resident #48 was provided a SNF ABN notice. Interview on 10/24/19 at 2:06 P.M. with the Director of Nursing (DON) verified Resident #48 skilled services ended on 09/11/19, the resident remained at the facility, had skilled benefit days remaining, and was not provided with a SNF ABN notice. The DON reported the facility recently discovered proper notices, including the SNF ABN notice, were not being provided to residents upon the completion of skilled services.
- Potential for harm · D2019-10-24 · tag F0623 — isolatedProvide 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 provide written transfer notification to the resident and/or resident's representative when they were hospitalized . This affected three (#27, #30 and #43) of four residents reviewed for hospitalization. The facility census was 61. Findings include: 1. Review of Resident #30's medical record revealed an admission date of 08/12/19. Diagnoses included psychotic disorder, metabolic encephalopathy, anoxic brain damage, atherosclerotic heart disease of native coronary artery without angina pectoris and paroxysmal atrial fibrillation. Review of the Minimum Data Set (MDS) assessment, dated 09/04/19, revealed Resident #30 was severely cognitively impaired. Review of the progress note, dated 08/03/19, indicated Resident #30 was sent to the hospital and admitted for a hip fracture. Further review of the medical record revealed there was no evidence of written notice to the resident and/or resident's representative for the reason for transfer to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-10-24 · tag F0625 — isolatedNotify 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 record review, staff interview, and review of facility policy, the facility failed to provide written bed hold information to the resident and/or resident's representative when the resident was hospitalized . This affected three (#27, #30 and #43) of four residents reviewed for hospitalization. The facility census was 61. Findings include: 1. Review of Resident #30's medical record revealed an admission date of 08/12/19. Diagnoses included psychotic disorder, metabolic encephalopathy, anoxic brain damage, atherosclerotic heart disease of native coronary artery without angina pectoris and paroxysmal atrial fibrillation. Review of the Minimum Data Set (MDS) assessment, dated 09/04/19, revealed Resident #30 was severely cognitively impaired. Review of the progress note, dated 08/03/19, indicated Resident #30 was sent to the hospital and admitted for a hip fracture. Further review of the medical record revealed no evidence of the facility's bed hold policy being provided to the resident's representative…
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 · D2019-10-24 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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 staff interview and medical record review, the facility failed to ensure a resident was monitored and gradual dose reductions were conducted for psychotropic medications. This affected one (Resident #21) of five residents reviewed for unnecessary medications. The facility census was 61. Findings include: Medical record review for Resident #21 revealed the resident was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, major depressive disorder, single episode, severe with psychotic features and unspecified dementia with behavioral disturbance. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/28/19, revealed the resident had moderately impaired cognitive skills for daily decision making, wandering behaviors occurred one to three days during the assessment, and antipsychotic medications were received on a routine basis only. Review of the hospital discharge orders, dated 12/26/18, revealed Resident #21 was diagnosed with major depressive disorder with psychosis…
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
No federal fines in the current CMS record. 1 Medicare payment denial on record.
- Medicare payment denial — starting 2025-12-24 for 35 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to EXCEPTIONAL LIVING CENTERS — 10 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.7 | -0.7 vs chain |
| Health inspection | 1 of 5 | 2.5 | -1.5 vs chain |
| Staffing | 3 of 5 | 2.4 | +0.6 vs chain |
| Quality measures | 5 of 5 | 3.9 | +1.1 vs chain |
The other 9 homes this chain runs (chain average 2.7★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| MEDICAL REHABILITATION CENTERS, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 01/23/2025 |
| LEXINGTON HEALTH MANAGEMENT LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/01/2023 |
| WATTS, AMY | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/01/2023 |
| WATTS, WALTER | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 02/01/2023 |
| MITAL, CHETNA | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/01/2023 |
| O'HARA, SCARLETT | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/01/2023 |
| CAMPBELL, BRENDA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/01/2023 |
CMS files one row per role, so the 15 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.
2 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 $703K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OH
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 365277. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-11-25, 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.