Darby Glenn Nursing And Rehabilitation Center
4787 Tremont Club Drive, Hilliard, OH 43026 · For profit - Corporation · 99 certified beds · (614) 777-6001 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- 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
- it has an abuse, neglect, or exploitation citation (F0602), cited Jan 2025
- it has 1 actual-harm citation
- a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| 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
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 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.
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 | 5.4% | 5.3% | 15.4% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 5.0% | 6.2% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.2% | 0.2% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.4% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 77.3% | 30.1% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.5% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 2.4% | 6.1% | 16.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 29.6% | 25.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.9% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 11.6% | 21.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 10.7% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.5% | 1.2% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 90.4% | 75.6% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 16.5% | 24.9% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 7.7% | 12.9% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.27 | 1.73 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.48 | 1.80 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
48.4% 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 45 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 33.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 24 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 0.21 therapist hours per resident per day in 2026Q1 — more than 24% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 10% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 48.4%CMS range 36.2–58.6 | 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 | 11.3%CMS range 7.5–18.5 | 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 | 33.3% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 25.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 33.3% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 60.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 5.9% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.7%CMS range 4.3–14.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.03 | 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 99 beds and averages 93.8 residents a day — about 95% occupied, or roughly 5 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.41 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.56 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.03 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 3.03 hrs/resident/day on weekends vs 3.56 on weekdays — 15% thinner on weekends. RN hours go from 0.61 to 0.41 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 43% 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
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.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
25 citations, most serious first. The 11 most serious are shown; the remaining 14 are one tap away and print in full.
- Actual harm · G2022-02-11 · 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, observations, interviews with staff, a family member and Nurse Practitioner (NP) #263, and review of information from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to implement pressuring relieving interventions for a resident at risk for further skin breakdown due to existing pressure ulcers and failed to complete weekly skin assessments. This resulted in Actual Harm when staff failed to implement pressure relieving interventions to prevent further skin breakdown for Resident #49 resulting in the development of an avoidable Deep Tissue Injury (DTI) to the left heel. Resident #49 also had increased measurements in the coccyx and heel pressure ulcers and experienced discomfort during a dressing change. This affected one (#49) of four residents reviewed for pressure ulcers. The facility identified 10 current residents with pressure sores. Facility census was 91. Findings include: Review of the medical record for the Resident #49 revealed an admission date…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-02-10 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, interviews and facility policy review, the facility failed to ensure one resident (#69) received a nutritious vegetarian diet. This affected one resident (#69) of four residents reviewed for nutrition. The facility census was 93. Findings Include:Review of the medical record for resident #69 revealed an initial admission date of 02/09/17 with the diagnoses including but not limited to moderate protein calorie malnutrition, hypertension, anemia, major depression disorder, osteoarthritis, spinal stenosis, hyperlipidemia, constipation, polyneuropathy and hypothyroidism. Review of the plan of care dated 02/15/17 revealed the resident had the potential for alteration in nutrition and hydration related to at moderate risk for malnutrition, followed a vegetarian diet related to cultural patterns. Interventions included assist with set up of meal items as needed/requested, honor food preferences as able, medications as ordered, monitor consistency of diet served and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-10 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and review of facility policy, the facility failed to ensure non-pharmacological interventions were provided prior to the administration of as needed pain medications for Resident #5, #1 and #30, this affected three of four residents reviewed for pain management. The facility failed to ensure descriptions of pain were documented for Resident #1 and #30 which affected two of four residents reviewed for pain management. The facility census was 93.Findings include:1. Review of Resident #30's medical record revealed an admission date of 08/22/25 and diagnoses including ataxia, mild neurocognitive disorder due to known physiological condition without behavioral disturbance, anxiety disorder, and major depressive disorder. Review of Resident #30's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderately impaired cognition. Review of Resident #30's plan of care revised 10/15/25 revealed the resident was at risk for alteration in comfort…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-02-10 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary 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 interview, medical record review, and review of facility policy the facility failed to ensure pain parameters were in place for Resident #1, #30, and #66, who received multiple as needed pain medications. This affected three of four residents reviewed for pain management. The facility census was 93. Findings include:1. Review of Resident #30's medical record revealed an admission date of 08/22/25 and diagnoses including ataxia, mild neurocognitive disorder due to known physiological condition without behavioral disturbance, anxiety disorder, and major depressive disorder.Review of Resident #30's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderately impaired cognition.Review of Resident #30's plan of care revised 10/15/25 revealed the resident was at risk for alteration in comfort due to diagnoses, generalized pain, and impaired mobility. Interventions included administering medications as ordered, offering backrub or warm blankets, offering nonpharmacological…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-14 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on interview, medical record review, review of facility investigation, and review of facility self-reported incidents (SRI's) revealed the facility failed to ensure Resident #59's money was not misappropriated by facility staff. This affected one resident (#59) of three residents reviewed for misappropriation. The facility census was 94. Findings include: Review of the medical record for Resident #59 revealed an admission date of 11/10/24 with diagnoses including Parkinson's disease, type two diabetes mellitus, bipolar disease, anxiety disorder, dementia, and major depressive disorder. Review of Resident #59's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had intact cognition. Review of the SRI created 12/18/24 and completed 12/26/24 revealed an incident of misappropriation had been substantiated. Resident #59's wallet had been missing. Review of the narrative…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-25 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and observation, the facility failed to ensure Resident #65's bed was set to the proper setting to ensure comfort. This affected one resident (#65) of 18 reviewed for speciality mattresses. The facility census was 91. Findings include: Review of the medical record for Resident #65 revealed an admission date of 06/15/20 with diagnoses including cerebral infarction due to thrombosis of other cerebral artery, type 2 diabetes mellitus, need for assistance with personal care, anxiety, insomnia, lower back pain, hemiplegia, and major depressive disorder. Review of Resident #65's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she required maximal assistance for bed mobility. Review of Resident #65's medical record revealed an order dated 03/26/24 for a low air loss (LAL) mattress. Staff required to check placement and function every shift. Review of Resident #65's care plan dated 06/26/24 found she was at risk for alteration in comfort due to pain and hemiplegia. Interventions…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-25 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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 resident interview, family interview, staff interview, and policy review, the facility failed to ensure care conferences were held quarterly. This affected three residents (#22, #68, and #79) of six residents reviewed for care conferences. The facility census was 91. Findings include: 1. Review of medical record for Resident #22 revealed admission date of 02/12/23 with diagnoses including but not limited to paraplegia, congestive heart failure, cognitive communication deficit, and need for assistance with personal care. Review of Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact. Review of social service note dated 02/28/23 revealed care conference was held on this date with the resident. Review of social service note dated 10/04/23 revealed spoke with the resident and offered care conference. The resident declined. Social Worker let her know we would offer quarterly, and they could request one at anytime. Further review of the medical record revealed no further notes or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-25 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review, the facility failed to provide and offer Resident #65 activities per preference. This affected one resident (#65) of one resident reviewed for activities. The facility census was 91. Findings include: Review of the medical record for Resident #65 revealed an admission date of 06/15/20 with diagnoses including cerebral infarction due to thrombosis of other cerebral artery, type 2 diabetes mellitus, need for assistance with personal care, anxiety, insomnia, lower back pain, hemiplegia, and major depressive disorder. Review of Resident #65's activity assessment completed 03/11/24 revealed she prefers one-on-one (1:1) and small group activities. She enjoys bingo, television, pop music, and socializing. In line with her preferences, Resident #65 participates in bingo, crafts, happy hour/live music, and special events when she is up from bed. Activity staff will continue to invite, encourage, and assist her with activities as needed. Resident #65, who was recently…
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 · D2024-07-25 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and record review, the facility failed to identify and assess new skin impairment timely. This affected one resident (#62) of four reviewed for skin. Facility census was 91. Findings include: Review of the medical record for Resident #62 revealed an admission date of 11/10/21. Diagnoses included chronic obstructive pulmonary disease, kidney disease, hypertension, pulmonary embolism, atrial flutter and delusion disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 was cognitively intact and had no impairment in range of motion. The MDS revealed the resident was on an anticoagulant medication. Review of physician orders dated 06/25/23 for Eliquis (anticoagulant) 2.5 Milligrams (mg) tab with instructions to give one tab twice daily for atrial fibrillation. Facility had no orders for monitoring of bruising or bleeding. Review of the plan of care dated 05/14/24 revealed the resident was at risk of bleeding and bruising from anticoagulant…
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 · D2024-07-25 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, and staff interview, the facility failed to ensure tube feed was labeled and dated. This affected one resident (#79) of one reviewed for tube feed. The facility census was 91. Findings include: Review of medical record for Resident #79 revealed admission date of 06/28/23 with diagnoses including but not limited to chronic obstructive pulmonary disease, type two diabetes, moderate protein-calorie malnutrition, dysphagia, kidney disease, hypertension, major depressive disorder, malignant neoplasm of unspecified part of right bronchus or lung, and acquired absence of lung. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. The resident was set up/supervision for meals. The resident rejected care one to three days during the seven day look back period. No weight loss or gain noted. Fifty one percent or more calories received from tube feeding and 501 milliliters a day or more average fluid intake per day provided by tube…
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 · D2024-04-29 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, medical record review, staff interview and review of manufacturer's instructions, the facility failed to ensure medication error rates were not five percent or greater when staff failed to prime two insulin pens for Resident #7. There was 32 medication administration opportunities with two errors, for a medication error rate of 6.25%. This affected one (Resident #7) of three residents reviewed for medication administration. The facility census was 93. Findings include: Review of Resident #7's medical record revealed an admission date of 02/04/23. Diagnoses included type II diabetes mellitus, chronic congestive heart failure (CHF), hyperlipidemia, hypertension, atherosclerotic heart disease of native coronary artery, atrial fibrillation, hypothyroidism, anxiety disorder, major depressive disorder, low back pain, chronic kidney disease, and gastro-esophageal reflux disease (GERD). Review of a physician order dated 03/22/23 revealed humalog kwikpen subcutaneous solution pen-injector 100 unit/milliliter insulin lispro inject 15 units subcutaneously three times 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.
Show the remaining 14 citations
- Potential for harm · D2024-04-29 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, medical record review, staff interview, and review of insulin pen manufacturer's instructions, the facility failed to ensure residents were free from significant medication errors when staff failed to prime two insulin pens for Resident #7. This affected one (Resident #7) of three residents reviewed for medication administration. The facility census was 93. Findings include: Review of Resident #7's medical record revealed an admission date of 02/04/23. Diagnoses included type II diabetes mellitus, chronic congestive heart failure (CHF), hyperlipidemia, hypertension, atherosclerotic heart disease of native coronary artery, atrial fibrillation, hypothyroidism, anxiety disorder, major depressive disorder, low back pain, chronic kidney disease, and gastro-esophageal reflux disease (GERD). Review of a physician order dated 03/22/23 revealed humalog kwikpen subcutaneous solution pen-injector 100 unit/milliliter insulin lispro inject 15 units subcutaneously three times a day related to type II diabetes mellitus, with additional units ordered based on blood sugar…
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 before2023-09-25 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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, staff and resident interview, and policy review the facility failed to ensure care conferences were provided quarterly for the residents. This affected three (#6, #20, and #42) of three residents reviewed for care conferences. The facility census was 97. Findings included: 1. Medical record review for Resident #6 revealed an admission date to the facility on [DATE]. Diagnosis included multiple sclerosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was cognitively intact. Review of a progress note dated 05/09/23 revealed Resident #6 and the family were offered a care conference. Review the progress notes from 08/01/23 through 09/24/23 revealed there was not any evidence a care conference was offered to the resident and family. Interview with Resident #6 on 09/25/23 at 10:37 A.M. revealed she had not received a care conference since she had been a resident at the facility. Interview with the Director of Nursing (DON) on 09/25/23 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 · D2023-09-25 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, observation, and policy review, the facility failed to ensure a resident, who was incontinent of bowel and bladder and dependent on staff for toileting, received the appropriate treatment and services for incontinence care. This affected one (#42) of three residents reviewed for incontinence care. The facility identified there were 22 residents who were incontinent of bowel and/or bladder. The facility census was 97. Findings include: Medical record review for Resident #42 revealed an admission date of 05/10/17. Diagnosis included multiple sclerosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 had moderately impaired cognition. Resident #42 was totally dependent on staff for toileting. Review of the care plan dated 06/01/23 revealed Resident #42 was completely incontinent for bowel and bladder. Observation on 09/21/23 at 10:37 A.M. with State Tested Nursing Aide (STNA) #132 revealed she provided the incontinence…
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 · E2022-02-11 · 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 observation, record review, staff interviews, review of Center for Disease Control and Prevention (CDC) guidleines, facility policy review, the facility failed to maintain infection control practices to prevent the spread of COVID-19. This had the potential to affect all residents except the eight COVID-19 positive residents (#5, #17, #20, #23, #44, #85, #90 and #394). Additionally, the facility failed to maintain acceptable infection control practices when handling medications. This deficient practice affected one (#43) of five residents reviewed for medication administration. The facility census was 91. Findings include: 1. Observations on 01/31/22 at 12:13 P.M., of Housekeeper #131 enter the COVID-19 unit without a gown or gloves. The Housekeeper #131 said she was not required to wear a gown or gloves on the COVID-19 unit. Additional observations of the Housekeeper #131 revealed she then exited the COVID-19 unit onto a non COVID-19 unit without changing her mask (N95 or surgical mask), or cleansing her eye protection (goggles or face shield). Housekeeper #131 verified…
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 · D2022-02-11 · tag F0553 — failed to let residents help plan their care — isolatedAllow resident to participate in the development and implementation of his or her person-centered plan of care.
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, resident and staff interviews, and review of policy, the facility failed to conduct quarterly care conferences for one resident. The affected one (#65) of three residents reviewed for care conferences. The facility census was 91. Findings include: Review of the medical record for Resident #65 revealed an admission date of 05/06/20 with medical diagnoses that included urinary tract infection, major depressive disorder, anxiety disorder, and myasthenia gravis without acute exacerbation. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE] for Resident #65 revealed the resident had intact cognition on the Brief Interview for Mental Status (BIMS) assessment. The resident required extensive assistance from one to two staff to complete Activities of Daily Living (ADLs). Review of the clinical census for Resident #65 revealed the resident had hospitalizations from 04/25/21 to 04/29/21, 10/15/21 to 10/19/21, 11/18/21 to 11/24/21, and 12/23/21 to 12/28/21. Review of the nurses notes…
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 before2022-02-11 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, resident and staff interviews, the facility failed to ensure a resident was provided with a bed mobility devices to assist with bed mobility. This affected one (#85) of one resident reviewed for bed mobility. The facility census was 91. Findings include: Review of Resident #85's medical record revealed an admission date of 07/22/21. Diagnoses included malignant neoplasm of prostate, diabetes mellitus, chronic obstructive pulmonary disease, dysphagia, paraplegia, anemia, hypertension, neurogenic bladder, hyperlipidemia and COVID-19. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed the resident had clear speech, understood others, made himself understood and had mild cognitive deficit. The resident required extensive assistance of two staff for bed mobility, toilet use and dependent on two staff for transfers. Review of the quarterly restraint/enabler decision tree dated 01/07/22 revealed the resident used one fourth side rails to assist 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 · D2022-02-11 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interviews, the facility failed to complete documentation and obtain written consent from the resident or resident representative for a change in code status. This affected one (#64) of one resident reviewed for advanced directives. The facility census was 91. Findings include: Review of the medical record for Resident #64 revealed an admission date of [DATE], with diagnoses including cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery, dysphagia, hypertension, aphasia, unspecified protein calorie malnutrition, hyperlipidemia, and cognitive communication deficit. Review of Resident #64's Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. Review of Resident #64's physician's orders revealed an order started on [DATE] and ended on [DATE] for the advance directive of Full Code, further review revealed an order dated [DATE] for the advanced directive of Do Not Resuscitate…
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 · D2022-02-11 · tag F0644 — isolatedCoordinate 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 record review and staff interview, the facility failed to complete a Prea-dmission Screening and Resident Review (PASARR) when for a residnet with a new mental diagnosis and failed to complete accurate PASARR's asseements. This affected three (#32, #58, #69) of three residents reviewed for PASARR's. The facility census was 91. Findings include: 1. Review of the medical record revealed Resident #69 admitted on [DATE], with diagnoses including chronic obstructive pulmonary disease, neuromuscular dysfunction of bladder, type two diabetes mellitus, chronic kidney disease stage IV, unspecified dementia, major depression, dysphagia, and Parkinson's disease. A diagnoses of unspecified psychosis not due to a substance or known physiological condition was added 03/15/21. Review of Resident #69's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #69's medical record revealed one Preadmission Screening Resident Review (PASARR) was completed 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.
- Potential for harm · Dcited before2022-02-11 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, family and staff interviews, the facility failed to provide individualized activities to meet the needs and interest for one resident. This affected one (#49) of three reviewed for activities. Facility census was 91. Findings include: Review of the medical record for the Resident #49 revealed an admission date of 05/14/21, with diagnoses included cognitive impairments following cerebral infarction, type two diabetes, muscle weakness, lack of coordination, disorder of muscle cognitive communication deficit, aphasia, hyperlipidemia, metabolic encephalopathy, and neuromuscular dysfunction of the bladder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 had cognitive impairment and required extensive assistance of two staff members for bed mobility and transfers and extensive one person assist for ambulation, toileting and hygiene. Review of the plan of care dated 11/30/21 revealed Resident #49 had preferences for daily life and person-centered…
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 before2022-02-11 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff and family interviews, the facility failed to encourage fluids per physician orders, monitor oral intake of fluids, and obtain weights according to physician orders. This affected one (#49) of eight residents reviewed for nutrition and hydration. Facility census was 91. Findings include: 1. Review of the medical record for the Resident #49 revealed an admission date of 05/14/21. Diagnoses included cognitive impairments following cerebral infarction, type two diabetes, muscle weakness, lack of coordination, disorder of muscle cognitive communication deficit, aphasia, hyperlipidemia, metabolic encephalopathy, and neuromuscular dysfunction of the bladder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 had cognitive deficit and required extensive assistance of two staff members for bed mobility and transfers and extensive one person assist ambulation, toileting and hygiene. a. Review of physician orders for 11/26/21 identified orders 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 · D2022-02-11 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record and staff interview, the facility failed to implement pharmacy recommendations. This affected one (#69) of five residents reviewed for unnecessary medications. The facility census was 91. Findings include: Review of the medical record revealed Resident #69 admitted on [DATE], with diagnoses including chronic obstructive pulmonary disease, neuromuscular dysfunction of bladder, type two diabetes mellitus, chronic kidney disease stage IV, unspecified dementia, major depression, dysphagia, unspecified psychosis and Parkinson's disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #69 had intact cognition. Review of the Resident #69's physician's orders revealed an order dated 06/07/21 to 02/02/22 for Seroquel 25 mg one tablet at bedtime and Seroquel 50 mg at bedtime. Review of the pharmacy recommendations for Resident #69 dated 04/08/21 and 07/07/21, revealed the pharmacist recommended the facility perform an Abnormal Involuntary Movement Scale…
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 before2022-02-11 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary 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, staff interview, review of policy, the facility failed to hold blood pressure medication when a resident's blood pressure was outside of the parameters (Resident #88). The facility also failed to monitor edema while on a diuretic medication and monitor bruising while on an anticoagulant medication for a resident (Resident #37). The deficient practices affected two (Residents #37 and #88) of six residents reviewed for unnecessary medications. The facility census was 91. Findings include: 1. Review of the medical record for Resident #88 revealed an admission date on 07/13/21, with medical diagnoses included arteriosclerotic heart disease, venous insufficiency, paroxysmal atrial fibrillation, personal history of transient ischemic attack (TIA) and cerebral infarction (stroke), essential primary hypertension (high blood pressure), and presence of automatic cardiac defibrillator. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #88 was rarely or…
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 · D2022-02-11 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and policy review, the facility failed to ensure medication were not left on resident's bedside and failed to ensure resident did not have medications that was not prescribed to her by the physician in her room. This affected two (#4 and #6) of five residents review medication. The facility census was 91. Findings include: 1. Record review of Resident #4 revealed an admission date of 07/26/21, with diagnoses including: cerebral infarction due to occlusion of right anterior cerebral artery, atrial fibrillation, osteoarthritis right knee, dysphagia, muscle weakness, need for assistance with personal care, aphasia, apraxia, protein calorie malnutrition, vitamin D deficiency, insomnia, and hypertension. Review of the quarterly minimum data set (MDS) dated [DATE] revealed the resident is rarely never understood, need assistance with personal hygiene, toilet use, dressing, bed mobility. Obervations on 01/31/22 at 12:09 P.M., revealed in Resident #4's room revealed a medicine cup…
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 · D2022-02-11 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard 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 and staff interview, the facility failed to keep an accurate medical record, when the nurse signed off on a skin assessment prior to completing it. This affected one (#37) of five residents reviewed for unnecessary medications. The facility census was 91. Findings include: Review of the medical record for Resident #37 revealed an admission date of 04/30/21, with diagnoses including Parkinson's disease, chronic obstructive pulmonary disease, type two diabetes mellitus, unspecified diastolic heart failure, arteriosclerotic heart disease of native coronary artery without angina pectoris, paroxysmal atrial fibrillation, major depressive disorder, unspecified dementia without behavioral disturbance, and dysphagia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 had intact cognition. The resident received an anticoagulant and diuretic for seven days during look back period. On 02/02/22 at 1:16 P.M., review of the February 2022 TAR revealed 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.
“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.
Part of a chain
This home belongs to FOUNDATIONS HEALTH SOLUTIONS — 64 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 | 5 of 5 | 4.1 | +0.9 vs chain |
| Health inspection | 4 of 5 | 3.9 | +0.1 vs chain |
| Staffing | 2 of 5 | 2.3 | -0.3 vs chain |
| Quality measures | 5 of 5 | 4.3 | +0.7 vs chain |
The other 63 homes this chain runs (chain average 4.1★, per CMS)
Showing 40 of 63; lowest-rated first.
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 | Since |
|---|---|---|---|
| COLLERAN, BRIAN | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2019 |
| KRYSTOWSKI, JOHN | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/01/2018 |
| FOUNDATIONS HEALTH SOLUTIONS, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2019 |
| MEEKS, AMANDA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/01/2024 |
| CHU, VINCENT | Individual | ADP OF THE SNF | since 08/09/2010 |
CMS files one row per role, so the 12 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.0M paid to related parties (affiliated landlords or management companies) in its most recent cost report.
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 366387. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-10, 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 →
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