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Crestwood Ridge Skilled Nursing And Rehab

141 Willettsville Pike, Hillsboro, OH 45133 · For profit - Corporation · 50 certified beds · (937) 393-6700 Medicare & Medicaid certified

Call the home — (937) 393-6700 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Jan 2025Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jan 2025
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • 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.

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

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
225 W Main St · (937) 393-2411 · Call to confirm hours
Pharmacy
109 W Main St · (937) 393-4423 · Call to confirm hours
Grocery
245 W Main St · (937) 393-4801 · Call to confirm hours
Park
State Route 73 · (937) 587-2796 · Typically dawn to dusk
Place of worship
7450 Fairground Rd · (937) 393-0168

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 3 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 rating3★
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 increased3.2%5.3%15.4%better than state — see note marked double-dagger below the table
Long-stay residents who lose too much weight3.1%6.2%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.2%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.4%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms25.0%30.1%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury9.1%3.2%3.3%worse
Long-stay residents whose ability to walk worsened2.9%6.1%16.1%better than state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication43.5%25.5%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%94.5%95.3%typical
Long-stay residents with pressure ulcers0.7%3.4%4.7%better
Long-stay residents with worsening bladder/bowel control14.7%21.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table11.1%8.8%17.1%better
Short-stay residents given the seasonal flu vaccine100.0%75.6%79.4%better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

12.4%U.S. median 10.7%
Went back to hospital
0.20U.S. median 0.31
Therapy hours / resident / day
0.07hours / resident / day
Physical therapy
0.11hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.20 therapist hours per resident per day in 2026Q1 — more than 22% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 6% 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 SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.4%CMS range 7.5–18.410.7%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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot 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 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 staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.081.02Oct 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

0.52
RN hours/ resident / day
0.76
LPN hours/ resident / day
1.91
Aide hours/ resident / day
3.18
Total nurse hours/ resident / day
0.45
RN hoursweekends
47.5%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 50 beds and averages 46.6 residents a day — about 93% occupied, or roughly 3 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 3.18 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.52 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.91 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 2.87 hrs/resident/day on weekends vs 3.31 on weekdays — 13% thinner on weekends. RN hours go from 0.55 to 0.45 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 48% is about the same as the national median of 45%.

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

Inspection trend

8
deficiencies at the latest standard inspection (2024-12-12)
8
at the previous standard inspection (2022-05-05)

Deficiencies are unchanged from the previous inspection. 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.

23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.

  • Actual harm · G2025-01-16 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and policy review, the facility failed to ensure residents were free from abuse. This resulted in an Actual Harm when Resident #12 was assaulted by Resident #39 on 01/11/25. Resident #12 was punched in the face and was temporarily unconscious. Resident #12 was evaluated at the local hospital, diagnosed with mild closed head injury, lip abrasion, and cervical strain. This affected one (Resident #12) of three residents reviewed for abuse. The facility census was 47. Findings include: Review of the medical record for Resident #12 revealed an admission date on 03/22/24. Diagnoses included intracranial injury with loss of consciousness on 06/29/23, major depressive disorder, dementia, personality disorder, generalized anxiety disorder, borderline personality disorder, bipolar two disorder, and post-traumatic stress disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/14/24, revealed that Resident #12 was cognitively intact. Resident #12 used a wheelchair to…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-12-12 · tag F0803 — failed to meet residents' dietary needs — widespread
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, review of dietary menus, and staff interview, the facility failed to serve all food items from the preplanned menu during meal service. This had the potential to affect all 44 residents in the facility. The census was 44. Findings include: Review of the dietary menu for week one, which contained the date of 12/11/24, revealed the meal was to include spaghetti sauce with meatballs, pasta, green beans, wheat bread, margarine, and cake. Observation on 12/11/24 at 11:32 P.M. revealed the cook was preparing the meals which included spaghetti sauce with meatballs, pasta, green beans, and cake. Further observation revealed the cook was not serving bread with the meals as indicated on the menu. Interview with Dietary Manager (DM) #167 on 12/11/24 at 2:07 P.M. verified the menu for 12/11/24 was to have wheat bread included with the meal and confirmed the facility did not serve bread on the lunch trays. DM #167 stated they just forgot to add the bread to the meal trays.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-12-12 · tag F0868 — widespread
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of Quality Assurance and Performance Improvement (QAPI) staff sign-in sheets and staff interview, the facility failed to have QAPI meetings at least quarterly and failed to have all required members in attendance. This had the potential to affect all 44 residents in the facility. The census was 44. Findings include: Review of the QAPI meeting sign-in sheet dated 01/11/24 revealed the facility's administrator, owner, board member, or other individual in a leadership role was not in attendance for this meeting. Further review of the QAPI sign-in sheets revealed a meeting was held 03/12/24 and the next meeting was not held until 08/22/24. There was no documentation of a second quarter (April, May, or June) QAPI meeting occurring in 2024. Interview with the Administrator on 12/12/24 at 1:40 P.M. verified the facility did not have the administrator, owner, board member, or other individual in a leadership role attend the QAPI meeting on 01/11/24. The Administrator also verified the facility did not hold QAPI meetings at least quarterly as the facility had a meeting 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-12 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, medical record review, and review of facility policy, the facility failed to ensure a resident's dignity was maintained by placing a cover over a urinary catheter drainage bag. This affected one (#28) of three residents the facility identified as having indwelling urinary catheters. The facility census was 44. Findings include: Record review for Resident #28 revealed the resident was admitted to the facility on [DATE] and had diagnoses including muscle weakness, neuromuscular dysfunction, and spastic diplegic cerebral palsy. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 was assessed to have intact cognition and to have an indwelling urinary (Foley) catheter. Review of an active physician order dated 10/03/24 reveled Resident #28 was to have a 16 French Foley catheter in place. Observation on 12/09/24 at 12:40 P.M. revealed Resident #28 was lying in bed with the door open. The resident's Foley catheter drainage bag was hanging on the side…

    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 · D2024-12-12 · 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

    Based on medical record review and staff interview, the facility failed notify a physician of resident blood glucose levels when the level was above 400 milligrams per deciliter (mg/dL) as ordered. This affected one (#20) of five residents reviewed for unnecessary medications. The facility census was 44. Findings include: Review of Resident #20's medical record revealed an admission date of 03/29/24. Diagnoses included type two diabetes mellitus, unspecified severe protein calorie malnutrition, respiratory failure, major depressive disorder, generalized anxiety disorder, and dysphagia. Review of Resident #20's physician order dated 03/29/24 revealed the resident was ordered Humalog Kwikpen subcutaneous (SQ) solution pen-injector 100 unit/ml to be injected as per sliding scale before meals and at bed time for diabetes as followed: for blood glucose levels between zero (0) and 149 mg/dL, notify the physician and administer no insulin; between 150 mg/dL and 199 mg/dL, give two (2) units of insulin; between 200 mg/dL and 249 mg/dL, give four (4) units of insulin; between 250 mg/dL 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
  • Potential for harm · D2024-12-12 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) after receiving Medicare Part A services at the facility as required. This affected three (#04, #28, and #40) of three residents reviewed. The facility census 44. Findings include: 1. Record review for Resident #04 revealed the resident admitted to the facility on [DATE]. Diagnoses included diabetes mellitus, essential primary hypertension, schizoaffective disorder, major depressive disorder, anxiety disorder, and schizophrenia. Review of Resident #04's Minimum Data Set (MDS) assessment dated [DATE] revealed she was mildly cognitively impaired. Review of Resident #04's Medicare cut letter dated 09/20/24 revealed she was cut for Medicare skilled services effective 09/23/24; however, the facility failed to provide Resident #04 a SNF ABN. 2. Record review for Resident #28 revealed the resident admitted to facility on 11/28/24. Diagnoses included urinary…

    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 · D2024-12-12 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    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 complete a Significant Change in Status Assessment for a resident enrolled in a hospice program. This affected one (#44) of three residents reviewed for Minimum Data Set assessments. The facility census was 44. Findings include: Record review for Resident #44 revealed the resident admitted to the facility on [DATE]. Diagnoses included dyskinesia, psychosis, essential primary hypertension, dementia, carbuncle, gout, depression, and adult failure to thrive. Review of Resident #44's progress notes dated 09/04/24 revealed the facility called to notify Resident #44's family of a change in condition. Further review of the progress notes confirmed Resident #44 was admitted to hospice services effective 09/12/24. Review of Resident #44's contract for hospice confirmed hospice services were effective on 09/12/24. Further review of Resident #44's medical record revealed no Significant Change in Status Minimum Data Set (MDS) assessment was completed…

    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 · D2024-12-12 · 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 staff interview and medical record review, the facility failed to to ensure Pre-admission Screening and Resident Review (PASARR) documents were accurate regarding resident current conditions and diagnoses. This affected two (#23 and #27) of two residents reviewed for PASARR documents. The census was 44. Findings include: 1. Review of Resident #27's medical record revealed an admission date of 07/14/23. Diagnoses included nephropathy induced by other drugs, type two diabetes mellitus with diabetic neuropathy, cellulitis, adult failure to thrive, hyperlipidemia, gout due to renal impairment, anxiety disorder, and bipolar disorder manic without psychotic features. Review of Resident #27's medical record revealed on 05/15/24 the resident had a new diagnosis of bipolar disorder manic without psychotic features. Review of Resident #27's most current PASARR dated 09/08/23 revealed there was no updated diagnosis of bipolar disorder manic without psychotic features. Interview with Regional Nurse #200 on 12/12/24…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-12 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review and staff interview, the facility failed develop a plan of care to address a resident's post traumatic stress disorder. This affected one (#31) of one residents reviewed for behavior and emotional needs. The facility identified five residents with a diagnosis of post traumatic stress disorder. The facility census was 44. Findings include: Review of Resident #31's medical record revealed an admission date of 09/08/22 with diagnoses including traumatic brain injury, paranoid schizophrenia, hemiplegia affecting the left non-dominant side, psychotic disorder with delusions, auditory and visual hallucinations, suicidal ideations, paranoid personality disorder, major depressive disorder, hereditary and idiopathic neuropathy, post traumatic stress disorder, homicidal ideations, edema, and hyperlipidemia. Review of the 11/08/24 quarterly Minimum Data Set (MDS) assessment revealed Resident #31 was cognitively intact and used a wheelchair to aid in mobility. The resident was coded as having a diagnosis of post traumatic stress disorder (PTSD). Further review of…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-10 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure Resident #49's legal guardian was provided, in writing a transfer/discharge notice at the time the resident was transferred to the hospital as required. This affected one resident (#49) of three residents reviewed for hospitalization. The facility census was 47. Findings include: Review of the medical record revealed Resident #49 was admitted to the facility on [DATE] with diagnoses including unspecified psychosis, post-traumatic stress disorder, Bipolar disorder, schizoaffective disorder, chronic obstructive pulmonary disease, suicide attempts, and intellectual disabilities. Review of admission records revealed this resident had a court appointed guardian, with an effective date of 06/13/22. The resident also had a Medicaid payor source. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 had a Brief Interview Mental Status (BIMS) score of ten out of 15 which indicated she had moderate cognitive…

    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 · D2024-08-10 · 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 record review and interview the facility failed to provide a written bed-hold notice to Resident #49 and Resident #49's legal guardian at the time of the resident's transfer to the hospital as required. This affected one resident (#49) of three residents reviewed for hospitalization. The facility census was 47. Findings include: Review of the medical record revealed Resident #49 was admitted to the facility on [DATE] with diagnoses including unspecified psychosis, post-traumatic stress disorder, Bipolar disorder, schizoaffective disorder, chronic obstructive pulmonary disease, suicide attempts, and intellectual disabilities. Review of admission records revealed this resident had a court appointed guardian, with an effective date of 06/13/22. The resident also had a Medicaid payor source. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 had a Brief Interview Mental Status (BIMS) score of ten out of 15 which indicated she had moderate cognitive impairment.…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 12 citations
  • Potential for harm · D2024-08-10 · tag F0626 — isolated
    Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
    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, hospital record review and interview, the facility failed to allow Resident #49 to return to the facility upon discharge from the hospital. This affected one resident (#49) of three residents reviewed for hospitalization. The facility census was 47. Findings include: Review of the medical record revealed Resident #49 was admitted to the facility on [DATE] with diagnoses including unspecified psychosis, post-traumatic stress disorder, Bipolar disorder, schizoaffective disorder, chronic obstructive pulmonary disease, suicide attempts, and intellectual disabilities. Review of admission records revealed this resident had a court appointed guardian, with an effective date of 06/13/22. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 had a Brief Interview Mental Status (BIMS) score of ten out of 15 which indicated she had moderate cognitive impairment. Review of a nursing progress note dated 07/26/24 at 9:50 P.M. revealed the resident was sent to the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, review of the weather condition, review of Centers for Disease Control and Prevention (CDC) guidance, and resident and staff interviews, the facility failed to ensure staff provided adequate supervision to prevent a resident from be treated for hyperthermia during extreme weather conditions. This affected resident (Resident #8) of three residents reviewed for accidents. The facility census was 48. Findings include: Review of the medical record revealed Resident #8 was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, asthma, muscle wasting and atrophy, muscle weakness, and bipolar disorder. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #8 was cognitively intact, required supervision with wheeling 150 feet, and rejected care. Resident #8 felt it was somewhat important to go outside and get fresh air when the weather was nice. Review of the care plan dated 06/20/24 revealed Resident #8 has a history of refusing…

    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 · E2023-08-15 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and staff interview, the facility failed to ensure a safe environment when furniture obstructed the view of hallway's call lights and the handrails on both sides of the 100-unit hallway. This affected 24 residents, (#01, #02, #07, #08, #09, #10, #11, #12, #13, #14, #21, #22, #23, #24, #25, #26, #27, #28, #31, #32, #35, #40, #41 and #45) for call light obstruction and five residents (#14, # 22, #24, #25, and #40) who required the use of the handrails. The total facility census was 45. Findings Include: Observation on 08/14/23 at 5:30 P.M. and on 08/15/23 at 8:12 A.M. to 4:00 P.M., revealed wardrobe furniture, measuring approximately three feet wide and seven feet tall, were on both sides of the resident occupied 100-unit hallway. The call lights were obstructed from sight and the handrails were blocked from the resident's usage. Review of the resident census listings dated 08/14/23, revealed there were 24 residents, (#01, #02, #07, #08, #09, #10, #11, #12, #13, #14, #21, #22, #23, #24, #25, #26, #27, #28, #31, #32, #35, #40, #41 and # 45), who resided on the…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-05-05 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, facility policy and procedure review and interview the facility failed to ensure quarterly care conferences were held and included the resident. This affected one resident (#25) of three residents reviewed for care conferences. Findings include: Record review for Resident #25 revealed an admission date of 04/15/21 with diagnoses including myocardial infarction, hypertension, muscle weakness, osteoarthritis, hyperlipidemia, major depressive disorder, anxiety disorder, myasthenia gravis, dementia, complete rotator cuff tear or rupture and atherosclerotic heart disease. Review of the resident's electronic medical record revealed Minimum Data Set (MDS) 3.0 assessments were completed on 10/21/21, 11/19/21, 02/19/22, 03/24/22 and 04/05/22. Record review revealed the last documented care planning conference was held on 10/29/21. Review of the 04/05/22 quarterly Minimum Data Set (MDS) 3.0 assessment revealed the Resident was cognitively intact. On 05/02/22 at 9:16 A.M. interview with Resident #25 revealed she had not had a care conference in a long time. On 05/05/22…

    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 · D2022-05-05 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #24, who was dependent on staff for activity of daily living care, received adequate and timely assistance with routine nail care to promote proper hygiene. This affected one resident (#24) of four residents reviewed for activities of daily living (ADL) care. Findings include: Review of Resident #24's medical record revealed an admission date of 04/21/21. Resident #24 had diagnoses including Alzheimer's disease, chronic obstructive pulmonary disease (COPD) intervertebral disc degeneration lumbar region, restlessness and agitation, hypertension, urge incontinence, insomnia, diabetes mellitus, major depressive disorder, psychosis and COVID-19. Review of the plan of care, dated 05/10/21 revealed the resident was at risk for decline in ADL function related to Alzheimer's disease and psychosis. Interventions included encourage resident participation while performing ADL, break tasks down so that ADLs were easier for resident to perform and make adjustments to…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-05-05 · 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

    Based on observation, record review and interview the facility failed to comprehensively assess and monitor multiple areas of bruising for Resident #232. This affected one resident (#232) of one resident reviewed for skin conditions. Findings include: Review of Resident #232's medical record revealed an admission date of 05/01/22 with the admitting diagnoses of chronic respiratory failure, pneumonia, hypertension, chronic obstructive pulmonary disease (COPD), heart failure, dementia and anxiety disorder. Review of the resident's admission Packet, dated 05/01/22 revealed the resident was admitted to the facility with a large bruise covering the left knee, a large bruise over the left forearm and scattered bruising over body. Further review of the medical record failed to provide an assessment for each bruise; the resident had multiple bruises to the body. Review of the plan of care, dated 05/01/22 revealed the resident was at risk for skin breakdown related to impaired mobility, underlying disease, weakness and debility related to pneumonia diagnosis. Interventions included encourage…

    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 · D2022-05-05 · 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

    Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure respiratory equipment was stored properly and to prevent infection for Resident #30 and Resident #232. This affected two residents (#30 and #232) of two residents reviewed for oxygen therapy. The facility identified four residents receiving respiratory treatments. Findings include: 1. Review of Resident #30's medical record revealed an initial admission date of 01/12/18 with the latest readmission of 02/08/22. Resident #30 had diagnoses including cholecystitis, chronic respiratory failure, chronic obstructive pulmonary disease (COPD), severe morbid obesity, esophagitis, neurogenic bladder, dysphagia, history of COVID-19, allergic rhinitis, hypertension, diabetes mellitus, chronic kidney disease, insomnia, congestive heart failure, atrial fibrillation, osteoarthritis, hyperlipidemia, hypothyroidism, restless leg syndrome and major depressive disorder. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 04/16/22 revealed the resident had clear…

    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 · D2022-05-05 · tag F0742 — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview the facility failed to ensure recommendations from a psychiatric consult were implemented timely for Resident #24, who had diagnoses of major depressive disorder and psychosis. This affected one resident (#24) of five residents reviewed for unnecessary medication use. Findings include: Review of Resident #24's medical record revealed an admission date of 04/21/21 with diagnoses including Alzheimer's disease, chronic obstructive pulmonary disease (COPD), intervertebral disc degeneration lumbar region, restlessness and agitation, hypertension, urge incontinence, insomnia, diabetes mellitus, major depressive disorder, psychosis and COVID-19. Review of the resident's physician medication orders, revealed an order dated 08/13/21 for Depakote Sprinkles delayed release 125 milligrams (mg) with the special instructions to administer four capsules by mouth twice a day. Review of a psychiatric consult, dated 03/09/22 revealed a recommendation was made to increase the Depakote Sprinkles delayed release to 500 mg by mouth twice a day and add 250 mg by mouth…

    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 · D2022-05-05 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review and interview the facility failed to ensure pharmacy recommendations were addressed timely for Resident #2, Resident #22 and Resident #24. This affected three residents (#2, #22 and #24) of five residents reviewed for unnecessary medication use. Findings include: 1. Review of Resident #24's medical record revealed an admission date of 04/21/21 with diagnoses including Alzheimer's disease, chronic obstructive pulmonary disease (COPD) intervertebral disc degeneration lumbar region, restlessness and agitation, hypertension, urge incontinence, insomnia, diabetes mellitus, major depressive disorder, psychosis and COVID-19. Review of a pharmacy recommendation, dated 01/13/22 revealed the pharmacist recommended a gradual dose reduction (GDR) for the resident's Tagament. The physician did not address the recommendation until 03/07/22. The physician agreed and decreased the Tagament to 400 milligrams once a day. Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 04/07/22 revealed the resident had clear speech, understood others,…

    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 · D2022-05-05 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure 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

    Based on record review, review of Nursing Handbook guidance and interview the facility failed to ensure the cardiac medication, Digoxin was only administered to Resident #22 when necessary and administered with adequate/proper monitoring. This affected one resident (#22) of five residents reviewed for unnecessary medication use. Findings Include: Review of Resident #22's medical record revealed an admission date of 03/25/22 with diagnoses including myocardial infarction, angina pectoris, atrial fibrillation, congestive heart failure, generalized muscle weakness, CVA with left sided hemiplegia, dysphagia, speech disturbances, constipation, hypertension, hyperlipidemia, atrial flutter, GERD and protein-calorie malnutrition. Review of a pharmacy recommendation, dated 03/31/22 revealed the pharmacist recommended to add administration parameters to hold for the medication Digoxin if the resident's apical pulse was less than 60 beats per minute (BPM). Further review revealed the physician did not address the recommendation unit 05/02/22. Review of the resident's comprehensive Minimum Data…

    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 · D2022-05-05 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, facility policy and procedure review and interview the facility failed to ensure adequate justification and ineffective non-pharmacological interventions prior to the administration of psychoactive medications for Resident #24. This affected one resident (#24) of five residents reviewed for unnecessary medication use. Findings include: Review of Resident #24's medical record revealed an admission date of 04/21/21 with diagnoses including Alzheimer's disease, chronic obstructive pulmonary disease (COPD) intervertebral disc degeneration lumbar region, restlessness and agitation, hypertension, urge incontinence, insomnia, diabetes mellitus, major depressive disorder, psychosis and COVID-19. Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 04/07/22 revealed the resident had clear speech, understood others, made himself understood and had a severe cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of zero. The assessment indicated the resident received anti-psychotic and anti-depressant…

    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 before2019-05-09 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility policy review and family and staff interview, the facility failed to ensure care conferences were conducted and included residents and the resident's representatives. This affected two residents (Resident #4 and #5) of sixteen residents reviewed. The facility census was 42. Findings include: 1. Review of Resident #5's medical records revealed the resident was admitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, dementia, anxiety and unspecified psychosis. Review of the resident's quarterly Minimum Data Set (MDS) assessment, dated 02/21/19, revealed the resident had severe cognitive impairment. The resident required extensive assistance for bed mobility, eating and dressing and required total dependence for toileting and transfers. Review of the resident's medical record revealed no documentation related to care conferences in the past year. Interview on 05/07/19 at 9:30 A.M. 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.

    Resident Assessment and Care Planning 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 CONTINUING HEALTHCARE SOLUTIONS — 12 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 4 of 52.1+1.9 vs chain
Health inspection 3 of 51.8+1.2 vs chain
Staffing 2 of 51.8+0.2 vs chain
Quality measures 5 of 54.3+0.7 vs chain
The other 11 homes this chain runs (chain average 2.1★, 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 / managerTypeRoleSince
BUNNER, MICHAELIndividualCORPORATE DIRECTORsince 11/18/2011
MALLETT, CHRISTOPHERIndividualCORPORATE DIRECTORsince 01/01/2013
PARSONS, BENJAMINIndividualCORPORATE DIRECTORsince 01/01/2013
SPRENGER, MARKIndividualCORPORATE DIRECTORsince 01/01/2014
SPRENGER, TIMOTHYIndividualCORPORATE DIRECTORsince 01/01/2013
HUGHEY, TRACYIndividualCORPORATE OFFICER; ADP OF THE SNFsince 01/01/2026
KAUFFMAN, KEVINIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/01/2024
CONTINUING HEALTHCARE SOLUTIONS INCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 05/01/2012
MILLER, MICHAELIndividualTRUSTEE OF THE SNFsince 01/01/2026

CMS files one row per role, so the 12 rows in the source record cover these 9 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.

$4.0M
Net patient revenuemost recent cost report
-4.5%
Operating marginrevenue minus expenses
$204K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 63%Medicare 7%Other / private 30%

This home reported $204K 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

$268per resident / day
operating cost
$8,148per month
≈ monthly operating cost
$256per 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 365934. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-12-12, 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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