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Doverwood Village

4195 Hamilton Mason Road, Hamilton, OH 45011 · For profit - Corporation · 99 certified beds · (513) 777-1400 Medicare & Medicaid certified

Call the home — (513) 777-1400 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 19 lower-level deficiencies on record (see below)
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • a high number of inspection citations overall (19) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (2/5)
  • about 20% of its spending goes to commonly-owned related companies

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.

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

Location & what’s nearby

Hospital
Urgent care / clinic
7921 Jessies Way · (513) 844-1111 · Call to confirm hours
Pharmacy
3369 Princeton Rd · (513) 714-0006 · Call to confirm hours
Grocery
4005 Hamilton Mason Rd · (513) 893-2400 · Call to confirm hours
Park
5119 Grandin Ridge Dr · (513) 759-7500 · Typically dawn to dusk
Place of worship
4394 Tylersville Rd · (513) 942-0111

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
Short-stay residentsrehab / post-hospital 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 improved from 4 to 5 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 rating5★
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 increased0.5%5.3%15.4%better 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 bladder0.6%0.2%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.4%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms31.4%30.1%6.5%typical for the 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 injury3.2%3.2%3.3%typical
Long-stay residents whose ability to walk worsened0.0%6.1%16.1%check this — see note marked star below the table
Long-stay residents on antianxiety or hypnotic medication18.5%25.5%18.9%typical
Long-stay residents given the seasonal flu vaccine100.0%94.5%95.3%typical
Long-stay residents with pressure ulcers2.7%3.4%4.7%better
Long-stay residents with worsening bladder/bowel control20.5%21.4%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table3.5%8.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.2%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine98.1%75.6%79.4%better
Short-stay residents rehospitalized after admission21.9%24.9%22.6%typical
Short-stay residents with an outpatient ER visit12.4%12.9%12.0%typical

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

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.

59.4% 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 204 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

59.4%U.S. median 51.5%
Got home and stayed home
11.0%U.S. median 10.7%
Went back to hospital
86.9%U.S. median 56.6%
Met the expected recovery
0.46U.S. median 0.31
Therapy hours / resident / day
0.23hours / resident / day
Physical therapy
0.20hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 86.9% 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 84 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 0.46 therapist hours per resident per day in 2026Q1 — more than 77% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 15% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF59.4%CMS range 51.1–65.851.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.0%CMS range 8.7–14.210.7%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 discharge86.9%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 discharge75.0%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 discharge86.9%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 identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care 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 dischargenot 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 stay0.7%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 worsened0.7%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.0%CMS range 3.9–11.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.101.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.58
RN hours/ resident / day
1.12
LPN hours/ resident / day
2.73
Aide hours/ resident / day
4.42
Total nurse hours/ resident / day
0.29
RN hoursweekends
45.0%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 99 beds and averages 91.1 residents a day — about 92% 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 4.42 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.58 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.73 is at or above 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 4.09 hrs/resident/day on weekends vs 4.56 on weekdays — 10% thinner on weekends. RN hours go from 0.69 to 0.29 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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

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

Inspection trend

4
deficiencies at the latest standard inspection (2025-06-27)
11
at the previous standard inspection (2022-09-28)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

19 citations, most serious first. The 10 most serious are shown; the remaining 9 are one tap away and print in full.

  • Potential for harm · F2025-06-27 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and facility policy review, the facility failed to ensure that dented cans were removed from the dry storage area in the kitchen. This had the potential to affect all 83 residents residing in the facility. The census was 83.Findings include:Observations of the kitchen dry storage area on 06/23/25 at 10:04 A.M. with the Chef revealed 13 dented cans amongst the canned goods. The dented cans included two (2) seven-pound (lb.) cans of pudding, 2 five lb. cans of spinach, eight (8) six lb. cans of peaches, and one (1) seven lb. can of refried beans. During an interview on 06/23/25 at 10:06 A.M., the Chef stated she and the cooks put the canned food deliveries away. She stated [NAME] #2 stocked the canned peaches the prior Monday. She stated dented cans should be removed from the dry storage and placed in her office so she could submit them for credit and confirmed the dented cans. She stated botulism bacteria could get into the canned food if the dent caused a hole or broke the seal. She stated the dented canned food found should have been removed…

    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 · E2025-06-27 · tag F0925 — failed to control pests — pattern
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and resident representative interview, staff interview, medical record review, facility document and policy review, and review of corrective action documents, the facility failed to execute an effective pest control program for the prevention and control of mice in the facility. This affected four (#5, #12, #13, and #20) of 83 residents residing in the facility. The census was 83. Findings include: 1. Review of Resident #5's medical record revealed an admission date of 11/14/24. Diagnoses included major depressive disorder and adjustment disorder with anxiety.Review of a quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 04/09/25, revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS assessment indicated Resident #5 had no potential indicators of psychosis. During a concurrent interview and observation in Resident #5's room on 06/23/25 at 9:29…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-27 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, medical record review, and facility document and policy review, the facility failed to ensure services were provided to meet professional nursing standards of clinical practice when staff failed to date or initial intravenous tubing or a peripherally inserted central catheter line dressing when changed and failed to date and initial a wound dressing as required. This affected one (#41) of five residents reviewed for care and services. The census was 83. Findings include: Review of Resident #41's medical record revealed the resident admitted to the facility on [DATE] and most recently admitted the resident on 06/06/25. Medical diagnoses included acute osteomyelitis of the left ankle and foot and osteomyelitis of the vertebra, sacral, and sacrococcygeal region.Review of an admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 06/12/25, revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of three (3), which indicated 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-27 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review and staff interview, the facility failed to ensure wound care was documented accurately for one (#82) of three residents sampled for pressure ulcers. The census was 83. Findings include:Review of Resident #82's medical record revealed an admission date of 02/05/25. Diagnoses included multiple sclerosis, morbid obesity, hyperlipidemia, major depressive disorder, anxiety disorder, restless leg syndrome, essential hypertension, pulmonary embolism, constipation, neurogenic bowel, and neuromuscular dysfunction of the bladder. Review of an admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 02/11/25, revealed Resident #82 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS assessment indicated the resident was dependent on staff for toileting hygiene, rolling left to right, sitting to lying, lying to sitting on the side of the bed, sit to stand, chair/bed to chair transfer, toilet transfer, tub/shower transfer, and to walk 10 feet. The MDS assessment…

    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 · D2024-12-11 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, review of the transportation schedule, and review of the facility statement form the facility failed to ensure a resident had an adequate supply of oxygen when leaving the facility for a medical appointment. This affected one (#91) resident of three residents reviewed for respiratory care and services. The facility census was 90. Findings include: Medical record review for Resident #91 revealed an admission date of 03/20/24. Diagnoses included hemiplegia, hemiparesis following stroke, narcolepsy, type two diabetes mellitus, chronic heart failure, hypertension, pulmonary embolism, kidney failure and a history of covid. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #91 had significant cognitive impairment, required moderate to maximum assistance from staff for eating, toileting, transfers and bed mobility. Resident #91 had oxygen usage during the assessment period. Review of the plan of care revealed Resident #91 had…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-11 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, staff interview, policy review and review of the Standards of safe medication administration by a certified medication aide, the facility failed to ensure medications were administered by the staff member who prepared the medications. This affected one (#45) of four residents reviewed for medication administration. The facility census was 76. Finding include: Review of the medication record for Resident #45 revealed an admission on [DATE] with diagnoses including but not limited to hypoatremia, anemia, hypertensive orthostatic hypotension renal disease, dementia, and depression. Review of the quarterly Minimum Data Assessment (MDS) assessment dated [DATE] for Resident #45 revealed a brief interview for mental status revealing severe cognitive impairment. Resident #45 required moderate assistance with bed mobility, transfers, and toileting. Resident #45 required set up assistance for meals. Review of the plan of care for Resident #45 revealed the resident had impaired…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-07 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of controlled substance records, staff interview, and review of facility policy, the facility failed to ensure a resident's narcotic medication administration was accurately documented in the medical record. This affected one (#81) of three residents reviewed for narcotic medication administration. The census was 78. Findings include: Review of Resident #81 closed medical record revealed an admission date of 10/16/23. Diagnoses included pubic fracture, dorsalgia, osteoarthritis, and femur fracture. Resident #81 was discharged from the facility on 11/03/23. Review of an admission Minimum data Set (MDS) assessment dated [DATE] revealed Resident #81 was cognitively intact and needed some help with activities of daily living (ADL's). Review of physician orders revealed an order dated 10/16/23 for take 0.5 to one Oxycodone hydrochloride five milligram (mg) tablet (narcotic pain medication) every six hours for pain up to seven days. Review of the facility's Controlled Drug…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-27 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff, resident and resident representative interviews and policy review, the facility failed to notify the resident's representative when their was a change of condition. This affected one (#1) of three reviewed for change of condition. The census was 71. Findings included: Medical record review for Resident #1 revealed an admission date of 08/18/23. Medical diagnoses included history of fractures and atrial fibrillation. Review of admission Minimum Data Set, dated [DATE] revealed she was cognitively intact. Her functional status was extensive assistance for bed mobility, transfers, and toilet use. She was independent for eating. She was occasionally incontinent for bowel and bladder. Review of physician progress note dated 09/26/23 revealed Resident #1 was being seen for red, painful, and warm thumb noted by the therapy department. Review of the progress note dated 09/26/23 revealed there wasn't any evidence Resident #1's Representative was notified of this skin condition.…

    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 · D2022-09-28 · 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 medical record review, observation, staff interview, and policy review, the facility failed to ensure a resident was provided privacy. This affected one resident (#01) out of three residents reviewed. The facility census was 58. Findings Included: Review of the medical record for Resident #01 revealed an admission date of 12/21/21. Diagnoses included cerebrovascular disease, non-Hodgkin lymphoma, non-pressure chronic ulcer of the left ankle, atrial fibrillation, and disorientation. Review of the minimum data set (MDS) dated on 08/28/22 revealed Resident #01 was severely cognitively impaired. The resident required extensive two-person physical assistance for transfer, dressing, and personal hygiene. Resident #01 required total dependence for toilet use and bathing. Observation on 09/20/22 at 5:07 P.M. Resident #01 was lying in the bed with the sheet pulled up exposing his adult brief. The resident was awake, had no Geri sleeves (protective sleeves) on or the bolster to the bed. Observation on 09/20/22 at 5:08 P.M. Resident #01 could be seen from the hallway in bed with his…

    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 · D2022-09-28 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to ensure a resident's code status was accurately documented. This affected one resident (#13) out of one resident reviewed for advanced directives. The facility census was 58. Findings include: Review of the medical record for Resident #13 revealed she was admitted to the facility on [DATE]. Diagnoses included chronic diastolic heart failure, insomnia, chronic fatigue, chronic atrial fibrillation, anxiety disorder, severe protein calorie malnutrition, dysphasia, and history of coronavirus 2019 (COVID-19), Review of the quarterly [NAME] Data Set (MDS) assessment dated [DATE] revealed Resident #13 had impaired cognition. Review of the physician orders for Resident #13 revealed an order dated 12/16/19 and discontinued 12/19/19, Do Not Resuscitate Comfort Care (DNRCC). An order dated 12/19/19 and discontinued on 04/02/21 revealed a code status of DNRCC. Further review of the physician orders revealed an order dated 04/02/21 and…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 9 citations
  • Potential for harm · D2022-09-28 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff, resident, and resident representative interview, and policy review, the facility failed to ensure a safe, clean, and comfortable environment. This affected three residents (#21, #27, and #220) out of three residents reviewed. The facility census was 58. Findings include 1. Review of the medical record revealed Resident #21 was admitted to the facility on [DATE]. Diagnoses included Arnold Chiari Syndrome, hydrocephalus, encephalopathy, presence of cerebrospinal fluid drainage, dysphagia dysphonia, seizures, moderate protein calorie malnutrition, pressure ulcer of sacral region, chronic obstructive pulmonary disease, and hemiplegia. Review of the quarterly [NAME] data set (MDS) assessment dated [DATE] revealed Resident #21 had impaired cognition. The resident was totally dependent on staff with transfers, eating and toilet use. Resident #21 required extensive assistance from staff with bed mobility, dressing, and personal hygiene. Interview on 09/19/22 at 11:58…

    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 · D2022-09-28 · 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, staff interview, and review of the bed hold form, the facility failed to provide notification of the facility's bed hold policy. This affected one resident (#09) out of one resident reviewed. The facility census was 58. Findings include Review of the medical record revealed Resident #09 was admitted on [DATE]. Diagnoses included displaced trimalleolar fracture of right lower leg, major depressive disorder, generalized muscle weakness, anxiety disorder, dysphagia, depression, essential primary hypertension, and fibromyalgia. Review of the discharge with return anticipated minimum data set (MDS) assessment dated [DATE] revealed Resident #09 was cognitively intact. The resident required supervision from staff with transfers, personal hygiene, toilet use, and bed mobility. Review of Resident #09's progress notes revealed she was transferred to the hospital on [DATE] following a fall at the facility. Resident #09 was readmitted to the facility on [DATE] following her hospital stay.…

    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 · D2022-09-28 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview, and policy review, the facility failed to submit an updated Pre-admission Screenings and Resident Review (PASARR) following the addition of psychiatric diagnosis. This affected two Residents (#27, #35) out of two residents reviewed. The facility census was 58. Findings include 1. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE]. Diagnoses included diabetes mellitus, end stage renal disease, austro-esophageal reflux disease, acquired absence of right leg below the knee, major depressive disorder, insomnia, Parkinson's Disease, and hyperlipidemia. Review of the annual minimum data set (MDS) assessment dated [DATE] revealed Resident #27 was cognitively intact. The resident was totally dependent on staff with transfers. She required extensive assistance from staff with bed mobility, dressing, personal hygiene, and toilet use. Review of the PASARR provided by the facility for Resident #27 dated 09/12/17 (resident transferred from…

    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 · D2022-09-28 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff and resident interview, and observation, the facility failed to provide a base line plan of care to the resident or the resident representative within the required timeframe. This affected one resident (#61) out of three reviewed for plan of care. The facility census was 58. Findings include: Review of the medical record for Resident #61 revealed an admission date on 05/19/22. Diagnoses included acute and chronic respiratory failure, age related osteoporosis with pathological fracture, atrial fib, major depressive disorder, congestive heart failure, constipation, wedge compression, and schizoaffective disorder. Review of the quarterly Minimum Data Set, dated [DATE] revealed Resident #61 had intact cognition. Resident #61 presented no behaviors during the assessment period. Resident #61 required extensive assistance for bed mobility, transfers, toilet use, and personnel hygiene. Resident #61 was incontinent of bladder and has an ostomy. Resident #61 had a stage three pressure…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-09-28 · tag F0675 — failed to support quality of life — isolated
    Honor each resident's preferences, choices, values and beliefs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff and resident interview, and policy review, the facility failed to ensure call lights were within reach of the resident. This affected three residents (#17, #32, and #41) out of three residents reviewed for call light placement. The facility census was 58. Findings include: 1. Medical record review for Resident #41 revealed an admission date of 03/13/22. Diagnoses included respiratory failure, stroke, hypertension, and adult failure to thrive. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #41 had impaired cognition. Resident #41 required total assistance for bed mobility, transfers, and toilet use. Resident #41 required extensive assistance with eating. Review of the plan of care for Resident #41 dated 09/15/22 revealed the resident was at risk for self care deficits related to chronic obstructive pulmonary disease and dementia. She was alert and not consistent with making her needs known to staff. She received staff assistance…

    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 · D2022-09-28 · 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, observation, and staff and resident interview, the facility failed to ensure care planned interventions were implemented as ordered. This affected three residents (#01, #17, and #61) out of three residents reviewed for quality of care. The facility census was 58. Findings include 1. Medical record review for Resident #17 revealed an admission on [DATE]. Diagnoses included hemiplegia and hemiparesis, insomnia, toxic liver disease with hepatitis, atrial fibrillation, depression, diabetes, depressive disorder, heart disease, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 had cognitive impairment. Resident #17 required extensive assistance for bed mobility, dressing, total assist for transfers and toilet use. Resident #17 was coded with functional impairment on bilateral upper extremities. Review of the plan of care for Resident #17 dated 09/05/22 revealed the resident had an activity of daily living self-care performance…

    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 · D2022-09-28 · 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

    Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure fall prevention interventions were implemented as ordered. This affected one resident (#01) out of three residents reviewed. The facility census was 58. Findings Include: Review of the medical record for Resident #01 revealed an admission date of 12/21/21. Diagnosis included cerebrovascular disease, non-Hodgkin lymphoma, non-pressure chronic ulcer of the left ankle, atrial fibrillation, and disorientation. Review of the minimum data set (MDS) assessment dated on 08/28/22 revealed Resident #01 was severely cognitively impaired. The resident required extensive two-person physical assistance for transfer, dressing, and personal hygiene. Resident #01 required total dependence for toilet use and bathing. Review of the plan of care dated on 09/02/22 revealed Resident #01 was at risk for falls related to transient ischemic attacks (TIA), and a history of atrial fibrillation. Resident #01 was non-ambulatory but used a wheelchair. Interventions included an air mattress 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-09-28 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff and resident interview, and policy review, the facility failed to ensure medications were safely stored. This affected three residents (#47, #26, and #48) out of seven residents reviewed for medication storage. The facility census was 58. Findings include: 1. Medical record review for Resident #47 revealed an admission date of 02/17/22. Diagnoses included chronic kidney disease, ischemic cardiomyopathy, falls, anemia, heart failure, and bullous pemphigoid (a rare skin condition causing large, fluid filled blisters). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 had impaired cognition. Resident #47 required extensive assistance for bed mobility and toilet use. Observation on 09/19/22 at 8:15 A.M. revealed Resident #47 was resting in bed watching television. A tube of diphenhydramine cream two percent (%) was located on the bedside table. The tube was labeled with a prescription for use for Resident #47. Interview on…

    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 · D2022-09-28 · 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 medical record review, observation, staff interview, and policy review, the facility failed to ensure resident medications were handled in a sanitary manner to decrease the potential of infection. This affected one resident (#19) out of four residents observed for medication administration. The facility census was 58. Findings include: Review of the medical record for Resident #19 revealed an admission date of 2/21/22. Diagnoses included type two diabetes, dementia with behavioral disturbances, hypertension, chronic kidney disease, anxiety disorder, congestive heart failure, and acute kidney failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had impaired cognition. Review of the active physicians orders for Resident #19 revealed orders for Flonase suspension 50 micrograms (mcg) spray both nostrils one time a day for allergies, azelastine (an antihistamine) solution 137 mcg one spray in each nostrils every 12 hours, MiraLax (a laxative) packet 17 grams…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

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.

Part of a chain

This home belongs to CARESPRING — 16 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 5 of 54.0+1.0 vs chain
Health inspection 4 of 53.6+0.4 vs chain
Staffing 2 of 52.4-0.4 vs chain
Quality measures 5 of 54.6+0.4 vs chain
The other 15 homes this chain runs (chain average 4.0★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
CS HILLANDALE HOLDINGS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 05/10/2022
BARRY N BORTZ 06042009 TROrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 05/10/2022
BORTZ FAMILY IRREVOCABLE T/AOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 05/10/2022
CARESPRING HEALTH CARE HOLDINGS LPOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 05/10/2022
EPPERS, DAVIDIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICERNO PERCENTAGE PROVIDEDsince 05/10/2022
GRAMANN, SARAIndividualW-2 MANAGING EMPLOYEEsince 11/19/2023
CHIRUMBOLO, CHRISTOPHERIndividualCORPORATE OFFICERsince 05/10/2022
CARESPRING HEALTH CARE MANAGEMENT, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 07/01/2022

CMS files one row per role, so the 9 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.

5 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.

$10.1M
Net patient revenuemost recent cost report
-8.6%
Operating marginrevenue minus expenses
$2.2M
Related-party expense20% of expenses
Who pays — share of resident-days
Medicaid 16%Medicare 15%Other / private 69%

This home reported $2.2M paid to related parties — landlords or management companies under common ownership — equal to about 20% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$417per resident / day
operating cost
$12,681per month
≈ monthly operating cost
$384per 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 366040. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-27, 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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