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Gables Care Center

351 Lahm Drive, Hopedale, OH 43976 · For profit - Limited Liability company · 86 certified beds · (740) 937-2900 Medicare & Medicaid certified

Call the home — (740) 937-2900 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 29 lower-level deficiencies on record (see below)
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (28% vs 45% nationally) — better care continuity
Worth asking about
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • about 22% of its spending goes to commonly-owned related companies

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

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

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

Worth a closer look. This home's staffing and quality-measure ratings run 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, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
82424 Cadiz Jewett Rd · (740) 320-4048 · Call to confirm hours
Pharmacy
82424 Cadiz-Jewett Rd · (833) 427-5634 · Call to confirm hours
Grocery
430 Mill St · (740) 937-2906 · Call to confirm hours
Park
398 Village St · (740) 937-2355 · Typically dawn to dusk
Place of worship

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 4 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 4 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 rating4★
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 increased6.5%5.3%15.4%worse than state — see note marked double-dagger below the table
Long-stay residents who lose too much weight5.5%6.2%5.4%typical
Long-stay residents with a catheter left in their bladder0.4%0.2%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.9%0.4%2.0%worse than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms13.8%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 injury3.6%3.2%3.3%typical
Long-stay residents whose ability to walk worsened13.8%6.1%16.1%worse than state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication38.9%25.5%18.9%worse
Long-stay residents given the seasonal flu vaccine98.4%94.5%95.3%typical
Long-stay residents with pressure ulcers1.4%3.4%4.7%better
Long-stay residents with worsening bladder/bowel control22.5%21.4%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table12.3%8.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.5%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine83.6%75.6%79.4%typical
Short-stay residents rehospitalized after admission31.3%24.9%22.6%worse
Short-stay residents with an outpatient ER visit22.2%12.9%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.131.731.67worse
Long-stay outpatient ER visits per 1,000 resident days1.551.801.80better

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.

61.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 179 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

61.5%U.S. median 51.5%
Got home and stayed home
11.9%U.S. median 10.7%
Went back to hospital
58.5%U.S. median 56.6%
Met the expected recovery
0.50U.S. median 0.31
Therapy hours / resident / day
0.25hours / resident / day
Physical therapy
0.20hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 58.5% 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 94 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 0.50 therapist hours per resident per day in 2026Q1 — more than 81% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 18% 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 SNF61.5%CMS range 53.2–68.351.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.9%CMS range 9.1–15.210.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge58.5%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge58.5%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge59.6%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting99.1%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.2%CMS range 5.2–12.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.371.02Oct 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

0.73
RN hours/ resident / day
1.04
LPN hours/ resident / day
2.08
Aide hours/ resident / day
3.85
Total nurse hours/ resident / day
0.62
RN hoursweekends
28.0%
Total nursing turnover
15.8%
RN turnover

How full it usually is: this home is certified for 86 beds and averages 73.5 residents a day — about 85% occupied, or roughly 12 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 3.85 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.73 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.08 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 3.46 hrs/resident/day on weekends vs 4.01 on weekdays — 14% thinner on weekends. RN hours go from 0.78 to 0.62 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 28% is below 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

16
deficiencies at the latest standard inspection (2026-04-30)
3
at the previous standard inspection (2024-04-12)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

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

  • Potential for harm · Fcited before2026-04-30 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility's infection prevention and control program, review of the facility's legionella prevention program, review of infection logs and reports, observations, interviews with facility staff, review of Centers for Disease Control (CDC) guidelines, and facility policy review, the facility failed to identify and address infection trends, failed to adequately monitor water temperatures per the facility's water management plan, failed to ensure gloves were appropriately changed during incontinence care for Resident #74, and failed to perform hand hygiene to prevent the spread of infection prior to insulin administration for Resident #40. This had the potential to affect 75 residents residing in the facility. The facility census was 75.Findings include: 1.Review of the facility's monthly infection control logs for November 2025, December 2025, January 2026, February 2026, March 2026, and April 2026 revealed 29 treated urinary tract infections (UTI). Further review revealed 10 UTI's were tested…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-04-30 · tag F0655 — pattern
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to ensure residents were provided baseline care plans as required. This affected five residents (#6, #38, #84, #102) of 15 residents sampled for baseline care plans. The census was 75.Findings include: 1. Record review revealed Resident #6 admitted to the facility on [DATE] with diagnoses including cardiomegaly, pleural effusion, anxiety, constipation, and atrial fibrillation. Review of Resident #6 base line care plan dated 02/19/26 and baseline care plan summary dated 02/19/26 revealed no documentation of the resident being provided information or received a copy of the baseline care plan until seven days later on 02/26/26 when the resident signed the document. Interview with 04/27/26 at 12:37 P.M. with Resident #6 revealed they did not believe they had been part of a care plan conference of any kind. Interview on 04/29/26 at 2:30 P.M. with ADON #852 verified the signature of Resident #6 baseline care plan was dated 02/26/26 and the baseline care…

    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 · E2026-04-30 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    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, drug information review, policy review and interview, the facility failed to ensure medications were administered as ordered. There were four errors out of 25 medication administration opportunities for an error rate of 16%. This affected three residents (#40, #66 and #89) of six residents reviewed for medication administration. The facility census was 75. Findings include:1.Medical record review revealed Resident #89 was admitted on [DATE] with diagnoses including benign prostatic hyperplasia (BPH) with lower urinary tract symptoms.Review of the Order Summary Report dated April 2026 revealed Resident #89 was to receive Flomax 0.4 milligrams (mg) once a day for BPH.On 04/29/26 at 8:00 A.M., observation of the morning medication administration revealed Licensed Practical Nurse (LPN) #844 dispensed Resident #89's Flomax capsule from the individual packaging onto the top of the medication cart. The top of the medication cart was observed to have scattered white granules…

    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 · D2026-04-30 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents or their representative received written notice which specified the duration of the facility's bed-hold policy at the time of transfer. This affected two residents (#65 and #74) of three residents reviewed for hospitalization. The facility census was 75. Findings include: 1.Record review revealed Resident #65 admitted to the facility on [DATE] with diagnoses including obstructive sleep apnea, chronic respiratory failure, heart failure, myocardial infarction, nicotine dependence, and type two diabetes. Review of Resident #65's progress note dated 04/12/26 at 11:27 P.M. revealed Resident #65 had complaints of shortness of breath, lung sounds were diminished with little air movement, and the resident's oxygen saturation level was 91 percent (%) on room air. The resident was given an albuterol breathing treatment, after which Resident #65 stated they did not feel any better and had generalized abdominal pain. The facility's Medical…

    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 · D2026-04-30 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    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 interview, the facility failed to ensure comprehensive assessments were accurate. This affected two residents (#38 and #84) of 24 residents reviewed for comprehensive assessments. The census was 75. Findings include: 1. Medical record review revealed Resident #84 was admitted on [DATE] with diagnoses including hypertension, acute respiratory failure with hypoxia, abnormalities of gait and mobility, acute myocardial infarction, ventricular tachycardia and fibrillation, hypotension, cerebral infarction and exacerbation of chronic obstructive pulmonary disease. Review of the admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] and the 5-day MDS assessment dated [DATE] revealed Resident #84 was cognitively intact for daily decision-making and had adequate vision with the use of corrective lenses. On 04/27/26 at 3:53 P.M., interview with Resident #84 revealed he was in need of an eye exam. The resident stated he had not seen an eye doctor or had new glasses for over 10 years…

    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 · D2026-04-30 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to ensure comprehensive care plans were completed as required. This affected two residents (#5 and #39) of 25 residents reviewed for care plans. The census was 75.Findings include:1. Record review of Resident #39 revealed the resident was admitted on [DATE] with diagnoses including insomnia, dementia, anxiety, constipation, hypertension, depression, gastro esophageal reflux disease, dysphagia, and hypertension. Review of Resident #39 progress note dated 04/13/26 at 6:30 P.M. revealed an order was received for an indwelling urinary catheter. Review of Resident #39 progress note dated 04/14/26 at 11:45 A.M. revealed 900 milliliter (ML) or urine was emptied for the residents indwelling urinary catheter. Review of Resident #39 progress note dated 04/14/26 at 11:59 A.M. revealed the medical director advised staff to leave the residents indwelling urinary catheter in place. Review of Resident #39 progress note dated 04/19/26 at 3:57 P.M. revealed…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-30 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and interview, the facility failed to ensure dependent residents received adequate hygiene and showers. This affected one resident (#30) of one resident reviewed for activities of daily living. The census was 75. Findings include:Medical record review revealed Resident #30 was admitted on [DATE] with diagnoses including dementia, gastric ulcer with perforation, dysphagia, severe protein calorie malnutrition, cardiac arrhythmia, cognitive impairment and incontinence. Review of the 5-day admission Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #30 was severely impaired for daily decision-making, was dependent on staff for shower and bathing and required substantial/maximal assistance with personal hygiene. Review of the Kardex revealed Resident #30 was to receive a shower on Tuesday and Friday dayshift. Review of the Task: Bathing/Showers and Shower Refusals dated 04/01/26 to 04/30/26 revealed Resident #30 had received no showers/baths and had no shower…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-30 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of medical records, review of activity logs and calendars, and interviews with staff and residents, the facility failed to provide activities to meet the needs and interest for Resident #3 and Resident #84. This affected two residents (Resident #3 and Resident #84) of two residents reviewed for activities. The facility census was 75.Findings include: 1.Review of the medical record for Resident #3 revealed admission to the facility on [DATE] and a re-admission on [DATE] with diagnoses including subdural hemorrhage (brain bleed), stroke affecting right dominant side, macular degeneration (progressive disease of the eye leading to blindness), hearing loss, constipation, depression, and high blood pressure. Review of the annual Minimum Data Set (MDS) 3.0 comprehensive assessment completed on 10/07/25 for Resident #3 revealed a brief interview for mental status score of 15/15 indicating no cognitive impairment. Further review of the MDS revealed that Resident #3 was hard of hearing and had impaired…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-30 · tag F0685 — isolated
    Assist a resident in gaining access to vision and hearing 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 observation, medical record review, contract review, policy review and interview, the facility failed to ensure vision services were provided as needed. This affected one resident (#84) of one resident sampled for communication. The census was 75. Findings include: Medical record review revealed Resident #84 was admitted on [DATE] with diagnoses including hypertension, acute respiratory failure with hypoxia, abnormalities of gait and mobility, acute myocardial infarction, ventricular tachycardia and fibrillation, hypotension, cerebral infarction and exacerbation of chronic obstructive pulmonary disease. Review of the admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] and the 5-day MDS assessment dated [DATE] revealed Resident #84 was cognitively intact for daily decision-making and had adequate vision with the use of corrective lenses. Review of the Order Summary Report dated 03/19/26 revealed Resident #84 may have ancillary services including optometry evaluations and treatment as indicated.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-30 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review the facility failed to ensure a resident's incontinence brief was applied correctly resulting in the development of a pressure injury. This affected one resident (#74) of four residents reviewed for skin impairments. The census was 75.Findings include: Record review revealed Resident #74 was admitted to the facility on [DATE] with diagnoses including pulmonary hypertension, type two diabetes, chronic obstructive pulmonary disease, Stage 4 chronic kidney disease, insomnia, bradycardia, and atrial fibrillation. Review of Resident #74's care plan dated 12/08/23 revealed the resident was at risk for impaired skin integrity related to easily bruising, incontinence, reduced bed mobility, and thin fragile skin. Goals include the resident will not develop any areas of pressure-related breakdown and the residents' skin integrity will remain intact. Interventions included applying cushions to wheelchair, assist resident with turning and repositioning on routine rounds…

    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
Show the remaining 19 citations
  • Potential for harm · D2026-04-30 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide 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, infection control log review and interview, the facility failed to ensure residents were treated for urinary tract infections as ordered. This affected one resident (#78) of two residents reviewed for urinary tract infections. The census was 75.Findings include:Medical record review revealed Resident #78 was admitted on [DATE] with diagnoses including late onset Alzheimer's disease, chronic kidney disease stage 3, diabetes mellitus, incontinence and urinary tract infections. Review of the Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #78 was severely impaired for daily decision-making, was frequently incontinent of urine and had no urinary tract infections in the previous 30 days. Review of the Health Status Notes revealed on 04/03/26 Resident #78 was seen sitting on her buttocks in the doorway of another resident's room. Staff had observed the resident hit the side of her head on the doorway and slide to the floor. The resident was sent to the emergency room 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-30 · tag F0697 — failed to manage pain — isolated
    Provide 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 observation, medical record review, policy review and interview, the facility failed to provide adequate care and services to manage Resident #5's pain. This affected one resident (#5) of one sampled for pain management. The census was 75. Findings include: Medical record review revealed Resident #5 was admitted on [DATE] with diagnoses including chronic pain, unspecified contracture, cerebral infarction, chronic gout, osteoarthritis left shoulder and diabetic neuropathy. Review of the 5-day Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #5 was moderately impaired for daily decision-making, received scheduled and PRN (as needed) pain medications, the resident had complaints of frequent, moderate pain that had occasional effects on sleep, activities and day-to-day activities. Review of the medical record revealed Resident #5 was hospitalized for congestive heart failure on 04/24/26 and returned to the facility on [DATE]. Review of the Clinical admission Progress Notes dated 04/26/26…

    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 · D2026-04-30 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of medical records, staff interviews, and facility policy review, the facility failed to thoroughly address pharmacy recommendations in a timely manner. This affected three residents (#2, #78, and #83) of six residents reviewed for unnecessary medications. The facility census was 75. Findings include: 1.Review of the medical record for Resident #2 revealed admission to the facility on [DATE] with most recent re-entry on 02/26/26 for diagnoses including left above knee amputation, right below the knee amputation, chronic pain syndrome, vascular disease of extremities, high blood pressure, diabetes, heart disease, stage 3 kidney disease, degenerative joint disease of cervical (neck) spine, and carpal tunnel syndrome. Review of the monthly medication review recommendation from the pharmacist for Resident #2 revealed on 03/28/26 a note to the attending provider/prescriber by Consultant Pharmacist #732 noted that based on American Geriatric Society Beers Criteria, Amitriptyline (an 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 · D2026-04-30 · tag F0809 — failed to serve meals on a reasonable schedule — isolated
    Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, interviews, and facility policy review, the facility failed to ensure suitable and nourishing snack options were available for Resident #1. This affected one (Resident #1) of four residents reviewed for nutrition and hydration. The facility census was 75. Findings include: Review of the medical record for Resident #1 revealed admission the facility on 01/30/25 for diagnoses including osteoarthritis, heart disease, high blood pressure, right knee replacement, dementia-moderate with behavioral disturbances, left knee arthritis, history of viral hepatitis C, depression, and asthma. Further review of the most recent minimum data set (MDS) 3.0 quarterly assessment for Resident #1 dated 04/15/26 revealed a brief interview for mental status score of five, indicating severely impaired cognition. Further review of the MDS revealed Resident #1 required meal set up assistance, used of cane for mobility and had no noted swallowing or dental disorders.Review of the Quarterly…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-30 · tag F0881 — failed to use antibiotics responsibly — isolated
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of infection control reports, review of medical records, and staff interview, the facility failed to perform antibiotic stewardship for Resident #77 when the facility did not confirm a diagnosis of a urinary tract infection (UTI) using diagnostic testing before instituting and continuing antibiotic therapy. This affected one resident (#77) reviewed for antibiotic stewardship. The facility census was 75.Findings include: Review of the medical record for Resident #77 revealed admission to facility on 07/14/24 for diagnoses of severe dementia with psychotic behaviors, depression, anxiety, atrial fibrillation (an irregular heartbeat), high blood pressure, anemia (low blood count), insomnia (in ability to sleep), and moderate -protein calorie malnutrition.Review of the Minimum Data Set (MDS) 3.0 assessment for Resident #77 revealed a quarterly assessment completed on 01/16/26 with a brief interview for mental status score of 14/15 indicating cognitively intact at time of assessment. Further review of the MDS for Resident #77 revealed frequent urinary incontinence 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2026-02-11 · tag F0835 — failed to run the facility competently — widespread
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    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, review of the administrator job description, review of the resident rights policy and interviews, the facility failed to be administered in a manner that enabled all residents to attain/maintain their highest practicable physical, mental and psychosocial well-being. This had the potential to affect all 75 residents residing in the facility.Findings include: Review of the Resident Council Minutes dated 02/11/26 revealed residents want administration to be more present with the residents. Review of the administrator job description revealed the purpose of the administrator was to lead, guide, and direct the operations of the healthcare facility in accordance with local, state and federal regulations, standards and establish facility policies and procedures to provide appropriate care and services to residents period. Duties and responsibilities of the administrator include ensuring delivery of compassionate quality care and services across an interdisciplinary team approach as…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-02-11 · tag F0679 — failed to provide activities — pattern
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, activity calendars review, review of facility policy and interview, the facility failed to ensure activities were available to meet the needs of the residents and included adequate activity staff members to assist the residents with activities as needed. This affected three residents (Residents #39, #50 and #70) of five residents reviewed for activities and three residents (Resident #3, #44 and #67) observed during a group activity of 20 residents involved in the activity. The facility census was 75.Findings include: 1. Review of Resident Council meeting minutes from November of 2025 revealed residents reporting that activities are getting cut short because not enough staff, and residents wanted to know why the facility was no longer having live entertainers for music. The Administrator's response was that the facility was not cutting any activity short due to staffing and that the facility policy was to require all entertainers to have a tax identification number to be…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-12 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    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, and interview, the facility failed to ensure a resident with contractures received appropriate services to maintain mobility and prevent further decrease in range of motion. This affected one (Resident #51) of one residents reviewed for position/mobility. The facility census was 79. Findings include: Review of the medical record revealed Resident #51 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, diabetes mellitus, acute respiratory failure with hypoxia, congestive heart failure, spinal stenosis, contracture left hand, and dementia. Review of the Care Plan, dated 08/25/23 and revised on 04/10/24, revealed Resident #51 required double washcloth rolls to hands as tolerated to help prevent further decline in range of motion. Review of the Minimum Data Set (MDS) quarterly assessment, dated 02/14/24, indicated Resident #51's Brief Interview for Mental Status (BIMS) score was 05, which indicated severe cognitive impairment. The resident was…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-12 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based observation, record review, interview and policy review the facility failed to ensure an indwelling urinary catheter drainage bag and tubing were not resting on the floor. This affected one (Resident #3) of two residents reviewed for indwelling urinary catheter use. The facility identified eight residents (Residents #3, #4, #7, #15, #25, #32, #43 and #132) currently utilizing indwelling urinary catheters. The facility census was 79. Findings include: Review of Resident #3's medical record revealed an admission date of 03/25/21 with a readmission date of 06/29/23. Further review of the medical record including the minimum data set (MDS) 3.0 quarterly assessment with a reference date of 01/06/24 revealed Resident #3 had an intact and independent cognition level and used an indwelling urinary catheter (urinary collection device which is inserted into bladder and attached to an external drainage system and bag). Further review of the medical record revealed on 06/29/23 Resident #3 was ordered by the physician the use of an indwelling urinary catheter due to urinary obstruction…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-12 · tag F0881 — failed to use antibiotics responsibly — isolated
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of the infection control log, interview, and policy review the facility failed to ensure antibiotic use was appropriate and infections met treatment criteria. This affected one resident (#25) of two residents reviewed for antibiotic use. The facility census was 79. Finding included: Record review revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including dementia, abnormal posture, dysphagia, pleural effusion, diabetes mellitus, and chronic obstructive pulmonary disease. Review of Resident #25's urinalysis with culture and sensitivity, dated 01/15/24, revealed greater than 100,000 CFU/ml Klebsiella Pneumonia (bacteria). Review of Resident #25's physician order, dated 01/20/24, revealed the order to administer ciprofloxacin 500 milligrams (mg) one tablet by mouth, two times a day, for urinary tract infection until 01/30/24. Review of the Infection Control Log, dated January 2024, revealed the resident was ordered ciprofloxacin for a UTI, with 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-05-05 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility policy and procedure review and interview the facility failed to ensure the advance directives/code status for Resident #26 and Resident #281 were consistent between each residents' electronic health record, the hard chart/paper record on the unit and the sticker on the first page of the hard chart for quick reference. This affected two residents (#26 and #281) of two residents reviewed for advanced directives. Findings include: 1. Review of Resident #26's medical record revealed the resident was admitted to the facility on [DATE]. Resident #26 had diagnoses including acute and chronic respiratory failure with hypoxia, history of COVID-19, essential hypertension, hyperlipidemia, and atherosclerotic heart disease of native coronary artery without angina pectoris. A review of Resident #26's physician's orders revealed his advance directives/code status was a Do Not Resuscitate Comfort Care Arrest (DNR CC-A). The order had been in place since 06/13/19. A review of Resident #26's…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-05-05 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure Resident #73's physician was notified as ordered when the resident's blood glucose level (blood sugar) was greater than 400. This affected one resident (#73) of five residents reviewed for unnecessary medication use. Findings include: Review of the medical record revealed Resident #73 was admitted to the facility on [DATE]. Resident #73 had diagnoses including Parkinson's disease, hypertension, bipolar disorder, gout, polyneuropathy, long-term use of insulin, anxiety disorder, chronic pain syndrome, chronic kidney disease, cerebral infarction, protein-calorie malnutrition, osteoarthritis, breast cancer, dementia and inflammatory spondylopathy. Review of the May 2022 physician's order revealed Resident #73 had an order for Novolog (insulin) flex pen per sliding scale subcutaneously before meals and at bedtime. The sliding scale revealed for a blood glucose level from 0 to 150 give no insulin; for blood glucose level greater than 150- divide by 30…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-05-05 · 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, facility policy and procedure review and interview the facility failed to provide residents and resident representatives a written notice indicating the reason for the discharge and appeal rights. This affected two residents (#45 and #81) of 24 residents interviewed/reviewed for hospitalization. Findings include: 1. Review of Resident #45's medical record revealed diagnoses including chronic obstructive pulmonary disease, heart failure, chronic atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart) and malignant neoplasm of the urethra (a tube that connects the urinary bladder to the urinary meatus for the removal of urine from the body). A nursing note, dated [DATE] at 10:41 A.M. indicated the Urology Department at Veterans Affairs was notified Resident #45's left urostomy drain was leaking at the site on his back and of low drainage output was noted in the bag. The Urology Department was also notified of Resident #45 having blood…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-05-05 · 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, facility policy and procedure review and interview the facility failed to provide residents or resident representatives a written notice of the bed hold policy. This affected two residents (#45 and #81) of 24 residents interviewed/reviewed for hospitalization. Findings include: 1. Review of Resident #45's medical record revealed diagnoses including chronic obstructive pulmonary disease, heart failure, chronic atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart) and malignant neoplasm of the urethra (a tube that connects the urinary bladder to the urinary meatus for the removal of urine from the body). A nursing note dated [DATE] at 10:41 A.M. indicated the Urology Department at Veterans Affairs was notified Resident #45's left urostomy drain was leaking at the site on his back and of low drainage output was noted in the bag. The Urology Department was also notified of Resident #45 having blood from his penis. Resident #45 had an…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-05-05 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility policy and procedure review and interview the facility failed to ensure Resident #17 was invited to attend a quarterly care conference to be a part of the care planning process. This affected one resident (#17) of one resident reviewed for participation in care planning. Findings include: A review of Resident #17's medical record revealed the resident was admitted to the facility on [DATE]. Resident #17 had diagnoses including bilateral below the knee amputations, emphysema, mild intellectual disability, schizophrenia, chronic obstructive pulmonary disease and the need for assistance with personal care. A review of Resident #17's Minimum Data Set (MDS) 3.0 assessments revealed she had a significant change MDS assessment completed on 01/28/22. The prior MDS assessment was a quarterly MDS completed on 01/12/22. The significant change MDS indicated the resident had no communication issues and was cognitively intact. The resident was not known to have displayed any behaviors 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.

    Resident Assessment and Care Planning 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of physician standing orders and interview the facility failed to recheck Resident 23's blood glucose level after an initial blood sugar check was below 65 milligrams/ deciliter (mg/dl). This affected one resident (#23) of five residents reviewed for unnecessary medication use. Findings include: Review of Resident #23's medical record revealed the resident was admitted to the facility on [DATE] with a diagnosis that included adult onset diabetes mellitus. A review of Resident #23's physician's orders revealed an order to receive Lantus (long acting insulin) 19 units subcutaneously in the afternoon and 15 units at bedtime. The resident also had an order to receive Humalog (fast acting insulin) before meals and at bedtime as per sliding scale. The sliding scale included a formula to use dividing the blood sugar by 30 and then subtract 3 units. A review of Resident #23's medication administration record (MAR) for April 2022 revealed the resident's blood sugar was recorded as being 57…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-05-05 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, facility policy and procedure review and interview the facility failed to complete accurate assessments and failed to update the physician regarding failure to heal and/or decline in a pressure ulcer for Resident #72 to determine if a change in treatment was indicated. This affected one resident (#72) of one resident reviewed for pressure ulcers. Findings include: Review of Resident #72's medical record revealed an admission date of 03/29/22. Resident #72 had diagnoses including generalized muscle weakness, obesity, chronic congestive heart failure, chronic atrial fibrillation, post-surgical malabsorption and iron deficiency anemia. A wound assessment, dated 03/29/22 (admission) indicated Resident #72 had a pressure ulcer on the right heel which was assessed as a suspected deep tissue injury (SDTI) (a persistent non-blanchable deep red, maroon or purple discoloration). The wound bed had 100% necrosis (dead tissue). The ulcer measured three centimeters (cm) in length by three cm width with no depth noted. The physician was notified of the SDTI. Skin prep was…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-05-05 · 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 observation, record review and interview the facility failed to ensure fall interventions were in place for Resident #70, who had a history of falls to decrease the risk of additional falls. This affected one resident (#70) of two residents reviewed for falls. Findings include: Review of the medical record revealed Resident #70 was admitted to the facility on [DATE]. Resident #70 had diagnoses including edema, history of transient ischemic attack, cerebral infarction, protein-calorie malnutrition, cognitive communication deficit, polymyalgia rheumatica, bladder cancer, dementia, anxiety disorder, schizoaffective disorder and Alzheimer's disease. Review of the May 2022 physician's orders revealed Resident #70 had an order (dated 03/16/22) to wear gripper socks when she was not wearing her shoes. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/02/22 revealed Resident #70 had severely impaired cognition and required extensive assistance of two staff members for transfers. Further…

    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
  • No harm found · C2026-04-30 · tag F0577 — widespread
    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of survey result postings, review of the survey results binder, and interviews with residents and staff, the facility failed to provide the most recent survey results to residents. This had the potential to affect all 75 residents. The facility census was 75.Findings include: Interview on 04/27/26 at 2:00 P.M. during the Resident Council meeting revealed residents were unable to locate the facility's annual and complaint survey results and were not aware of the results of the last complaint survey conducted on 02/11/26. This was confirmed collectively by the Resident Council President, Resident #65, who reported he would like to know the results of the survey from February.Observation on 04/27/26 at 2:40 P.M. at the main nurse's station for halls 100, 200, and 300 revealed postings in two black frames on the wall with one reading, Past Survey Results, 2 years located in this frame behind this paper. To access, pull all 4 sides of black frame up and you will be able to remove the past survey results to review, please return to frame when finished. The second frame was…

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

    Resident Rights 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.

Who owns this facility

Owner / managerTypeRoleShareSince
CAPITAL HEALTH SERVICES INCOrganization5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 09/01/2005
BERNSEN, KARAIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICERNO PERCENTAGE PROVIDEDsince 01/01/2005
BERNSEN, KENNETHIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR; CORPORATE OFFICERNO PERCENTAGE PROVIDEDsince 01/01/2005
HUFF, JOSHUAIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICERNO PERCENTAGE PROVIDEDsince 01/01/2005
MANNING, SARAHIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICERNO PERCENTAGE PROVIDEDsince 01/01/2005

CMS files one row per role, so the 14 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.

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.

$9.7M
Net patient revenuemost recent cost report
-4.6%
Operating marginrevenue minus expenses
$2.2M
Related-party expense22% of expenses
Who pays — share of resident-days
Medicaid 60%Medicare 20%Other / private 20%

This home reported $2.2M paid to related parties — landlords or management companies under common ownership — equal to about 22% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

$345per resident / day
operating cost
$10,497per month
≈ monthly operating cost
$330per 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 366052. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-30, 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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