Ayden Healthcare Of Jackson
8668 State Route 93, Jackson, OH 45640 · For profit - Corporation · 82 certified beds · (740) 286-5026 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- it has an abuse, neglect, or exploitation citation (F0602), cited Aug 2023
- it has 1 actual-harm citation
- a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (2/5)
- about 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 2 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 3.4% | 5.3% | 15.4% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 9.0% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.4% | 0.2% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.5% | 0.4% | 2.0% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 14.6% | 30.1% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.8% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 1.3% | 6.1% | 16.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 31.2% | 25.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.2% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 21.6% | 21.4% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 7.3% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.9% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 82.9% | 75.6% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 16.5% | 24.9% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 20.7% | 12.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.66 | 1.73 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 3.37 | 1.80 | 1.80 | worse |
‡ 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.
54.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 42 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 44.8% 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 29 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 0.33 therapist hours per resident per day in 2026Q1 — more than 55% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 7% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 54.2%CMS range 39.1–68.9 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.9%CMS range 7.5–15.5 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 44.8% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 34.5% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 34.5% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 2.4% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 4.8% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.8%CMS range 4.1–14.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.97 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 82 beds and averages 59.5 residents a day — about 73% occupied, or roughly 22 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.06 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.56 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.87 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 2.81 hrs/resident/day on weekends vs 3.17 on weekdays — 11% thinner on weekends. RN hours go from 0.63 to 0.40 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 44% 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
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
28 citations, most serious first. The 11 most serious are shown; the remaining 17 are one tap away and print in full.
- Actual harm · Gcited before2021-10-07 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to implement physician ordered pressure ulcer interventions. Actual harm occurred to Resident #7 when the facility failed to place pressure reducing heel boots on the resident as ordered by the physician and the resident subsequently developed a pressure ulcer to his right heel. This affected one resident (#7) of the three residents reviewed for pressure ulcers and injuries. Findings include: Record review for Resident #7 revealed the resident was admitted to the facility on [DATE] with diagnoses including type two diabetes mellitus, abnormal weight loss, unspecified dementia with behavioral disturbance, restlessness, and agitation. The resident had no known allergies. Review of the significant change assessment, dated 9/20/21, revealed Resident #7 did not have any pressure ulcers and was at risk for pressure ulcer development. The resident required extensive assistance from two staff members with bed mobility, transfers, and toileting.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-05-29 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview, and facility policy review, the facility failed to ensure quarterly care conferences were conducted and the required departments were present at care conferences. This affected six residents (#12, #14, #27, #31,#37 and #64) of eight residents reviewed for care planning. The facility census was 71. Findings Include: 1. Review of the medical record for Resident #12 revealed an initial admission date of 04/16/18 with the latest readmission date of 12/10/24 with the diagnoses including but not limited to COPD, vitamin deficiency, allergic rhinitis, protein calorie malnutrition, squamous cell carcinoma of skin of right upper limb including shoulder, neoplasm of unspecified behavior of bone, soft tissue and skin, congestive heart failure, peripheral vascular disease, diabetes mellitus, hypothyroidism, hyperlipidemia, dementia, hypertension, chronic kidney disease and arthritis. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-29 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, interview and facility policy review, the facility failed to ensure one resident's (#35) primary care physician was notified of blood glucose levels above physician ordered parameters. This affected one resident (#35) of five residents reviewed for unnecessary medications. The facility census was 71. Findings Include: Review of the medical record for Resident #35 revealed an initial admission date of 03/15/19 with the latest readmission of 02/23/24 with the diagnoses including but not limited to diabetes mellitus with diabetic neuropathy, obstructive sleep apnea, chronic obstructive pulmonary disease, protein calorie malnutrition, vitamin D deficiency, hyperlipidemia, schizoaffective disorder bipolar type, congestive heart failure, hypertension, anxiety disorder, major depressive disorder, chronic kidney disease, insomnia due to mental disorder, post traumatic stress disorder, mood disorder and acquired absence of left leg below knee. Review of the plan of care dated 03/25/19 revealed the resident had diabetes mellitus and neuropathy. Interventions…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-29 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to accurately code antipsychotic medication on the Minimum Data Set (MDS) for Resident #7. This affected one resident (Resident #7) of 22 whose MDS was reviewed. The facility census was 71. Findings include: Review of the medical record review for Resident #7 revealed an admission date of 10/30/06 with diagnoses including schizophrenia, dementia, anxiety, moderate intellectual disability, major depressive disorder, bipolar disorder type two, and delusional disorder. Review of the physicians orders dated 05/25 revealed Resident #7 was prescribed and received zyprexa (antipsychotic medication) 2.5 milligrams by mouth daily related to schizophrenia. Review of the most recent MDS, a quarterly, dated 04/03/25 revealed Resident #7 had moderate cognitive impairment with physical and verbal behaviors. Resident #7 diagnoses included schizophrenia, dementia, anxiety, depression, bipolar disorder, and psychotic disorder. Resident #7 received antianxiety medication and antidepressant medication. The MDS did not include the antipsychotic…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-29 · tag F0655 — isolatedCreate 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 interview and record review the facility failed to complete the 48 hour baseline care plan to reflect the trauma Resident #72 received from a recent motor vehicle accident. This affected one resident (Resident #72) of nine reviewed for 48 hour baseline care plan. The facility census was 71. Finding include: Review of the medical record for Resident #72 revealed an admission date of 04/23/25 with diagnoses including unspecified fracture of lower end of right radius (long bone of the forearm that runs along the side of thumb and wrist), displaced trimalleolar fracture of right lower leg (ankle), unspecified fracture of right patella (knee), depression, mood disorder, and anxiety. Review of the physician orders dated 05/25 revealed Resident #72 was ordered and received ativan (antianxiety medication) 0.5 milligrams (mg) by mouth every eight hours for anxiety, duloxetine hydrochloride (antidepressant medication) 30 mg by mouth two times daily for depression and Amitriptyline hydrochloride 25 mg by mouth at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-29 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 interview and record review the facility failed to complete a comprehensive plan of care to reflect the trauma Resident #72 received from a recent motor vehicle accident or identify the triggers. This affected one (Resident #72) of 22 reviewed for plan of care. The facility census was 71. Review of the medical record for Resident #72 revealed an admission date of 04/23/25 with diagnoses including unspecified fracture of lower end of right radius (long bone of the forearm that runs along the side of thumb and wrist), displaced trimalleolar fracture of right lower leg (ankle), unspecified fracture of right patella (knee), depression, mood disorder and anxiety. Review of the physician orders dated 05/25 revealed Resident #72 was ordered and received ativan (antianxiety medication) 0.5 milligrams (mg) by mouth every eight hours for anxiety, duloxetine hydrochloride (antidepressant medication) 30 mg by mouth two times daily for depression and Amitriptyline hydrochloride 25 mg by mouth at bedtime for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-29 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, medical record review and interviews, the facility failed to ensure one resident (#62) skin interventions were in place as physician ordered. This affected one (Resident #62) of one resident reviewed for skin conditions. The facility census was 71. Findings Include: Review of the medical record for Resident #62 revealed an initial admission date of 04/27/24 with the diagnoses including but not limited to nontraumatic intracranial hemorrhage, Parkinsonism, protein calorie malnutrition, vitamin D deficiency, insomnia, depression, constipation, hyperlipidemia, cerebral infarction, hypertension, malaise, chronic obstructive pulmonary disease (COPD), anemia and asthma. Review of the plan of care dated 04/26/24 revealed the resident had the potential impairment to skin integrity related to debility, anemia,intracranial hemorrhage, impaired mobility and COPD. Interventions included avoid scratching and keep hands and body parts from excessive moisture, keep fingernails short, monitor for side effects of the antibiotics and over-the-counter pain medications: gastric…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-29 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review revealed the facility failed to ensure trauma was identified and assessed for causes and potential triggers. This affected one (Resident #72) of two residents reviewed for trauma informed care. The facility census was 71. Findings include: Review of the medical record for Resident #72 revealed an admission date of 04/23/25 with diagnoses including unspecified fracture of lower end of right radius (long bone of the forearm that runs along the side of thumb and wrist), displaced trimalleolar fracture of right lower leg (ankle), unspecified fracture of right patella (knee), depression, mood disorder and anxiety. Review of the physician orders dated 05/25 revealed Resident #72 was ordered and received ativan (antianxiety medication) 0.5 milligrams (mg) by mouth every eight hours for anxiety, duloxetine hydrochloride (antidepressant medication) 30 mg by mouth two times daily for depression and Amitriptyline hydrochloride 25 mg by mouth at bedtime for depression. Review of the most…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-05-07 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, review of Centers for Medicare and Medicaid (CMS) Quality, Safety, and Oversight (QSO) Memo 24-08-NH, staff interview, and policy review, the facility failed to ensure a resident's indwelling urinary catheter's collection bag was properly secured so it was not in direct contact with the floor. They also failed to ensure residents with chronic wounds and those with indwelling medical devices were placed in enhanced barrier precautions as required. This affected one (Resident #66) of three residents reviewed for indwelling urinary catheters and affected nine residents (5, #10, #32, #36, #40, #50, #63, #66, and #67) who the facility identified as having chronic wounds or indwelling medical devices. The facility census was 68. Findings include: 1. Review of Resident #66's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included adult onset diabetes mellitus and urinary retention. Review of Resident #66's physician's orders revealed he had an order…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-07 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, resident interview, and staff interview, the facility failed to ensure residents were treated with dignity when indwelling urinary catheter collection bags were not covered when the residents were in bed and left visible from the hallway. This affected two (Resident #40 and #66) of three residents reviewed for indwelling urinary catheters. The census was 68. Findings include: 1. Review of Resident #40's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included neuromuscular dysfunction of the bladder. Review of Resident #40's quarterly Minimum Data Set (MDS) assessment revealed the resident did not have any communication issues and was cognitively intact. The resident was identified as having the use of an indwelling urinary catheter. Review of Resident #40's care plans revealed she had a care plan in place for the use of an indwelling urinary catheter due to a neurogenic bladder. The interventions included the need to provide a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-07 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement 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 record review, review of the facility's infection control logs, review of McGeer's criteria for infection surveillance checklist, staff interview, and policy review, the facility failed to ensure a resident was not given antibiotics unless they met criteria for the treatment of a urinary tract infection (UTI). This affected one (Resident #40) of three residents reviewed for indwelling urinary catheter's/ UTI's. The census was 68. Findings include: Review of Resident #40's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included neuromuscular dysfunction of the bladder and flaccid neuropathic bladder not elsewhere classified. Review of Resident #40's physician's orders revealed she had the use of an indwelling urinary catheter due to urinary retention related to neurogenic bladder. The order had been in place since 02/22/24. Review of Resident #40's progress notes revealed she had been sent out to the hospital several times for concerns of a UTI. Most of her visits 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.
Show the remaining 17 citations
- Potential for harm · E2023-08-31 · tag F0644 — patternCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure Level I PASSARs (Preadmission Assessment and Resident Review) were correct and reflected the need for a Level II review for mental health diagnoses for Residents #15, #16, #43,and #44. This affected four (Residents #15, #16, #43, and #44) of four residents reviewed for PASSARs. The facility census was 67. Findings included: 1. Record review revealed Resident #16 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, aphasia following cerebrovascular disease, peripheral vascular disease, major depressive disorder with psychotic features, anxiety disorder, hypertension, and dysphagia. Review of a minimum data set (MDS) completed on 07/19/23 revealed Resident #16 has a brief status for mental status (BIMS) of 14 indicating intact cognition and a depression scale of 17 indicating moderately severe depression. Record review revealed Resident #16 received a diagnosis of psychosis on 03/03/21 and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-31 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and staff interview the facility failed to treat residents with dignity when a resident's urinary catheter collection bag was exposed with visible urine in the bag. This affected one resident (#50) of three residents reviewed for urinary catheters. The facility census was 67. Findings include: Record review of Resident #50 revealed an admission date of 06/15/23 with pertinent diagnoses of neuromuscular dysfunction of bladder, chronic obstructive pulmonary disease, acute cystitis, malignant neoplasm right bronchus or lung, disorder of adrenal gland, specified disorders of kidney ureter, acute kidney failure, chronic kidney disease stage three, hypertension, type two diabetes mellitus, anxiety disorder, and depression. Record review of the 07/26/23 modification of quarterly Minimum Data Set (MDS) assessment revealed the resident was cognitively intact and required extensive assistance for bed mobility, transfers, walk in room, dressing, toilet use, personal hygiene. The resident used a walker and wheelchair to aid in mobility and had an indwelling…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-31 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interviews, the facility failed to honor one residents (#72) preference for rising hour. This affected one of one resident reviewed for choices. The facility census was 67. Findings Include: Review of the medical record for Resident #72 revealed an initial admission date of 05/18/23 with diagnoses including Guillain-Barre syndrome, adult failure to thrive, congestive heart failure, hypertension, gastro-esophageal reflux disease, atrial fibrillation, obesity, urine retention, sleep apnea, quadriplegia, dysphagia, unstageable pressure ulcer to right heel. Review of the plan of care dated 05/18/23 revealed the resident was at risk for decline in activities of daily living (ADL) participation as evidenced by need for assistance with ADL, transfers, ambulation and toileting related to impaired mobility related to quadriplegia, Guillain barre, failure to thrive, congestive heart failure, depression and atrial fibrillation. Interventions included one half laptray to left side while in tilt and space wheelchair, offer resident to be up in chair daily…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-31 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, and staff interview the facility failed to have accurate advance directives in the electronic and medical record. This affected one resident (#5) of one resident reviewed for advanced directives. The facility census was 67. Findings include: Record review of Resident #5 revealed an admission date of 02/17/23 with pertinent diagnoses of: benign neoplasm of adrenal gland, chronic obstructive pulmonary disease, morbid obesity, vitamin D deficiency, hyperlipidemia, and obesity. Review of the 07/15/23 significant change Minimum Data Set (MDS) assessment revealed the resident was cognitively intact and required extensive assistance for bed mobility, transfer, locomotion on unit, and toilet use. The resident used a walker to aid in mobility and was occasionally incontinent of bladder and always continent of bowel. Review of the electronic medical record on 08/29/23 at 9:35 A.M. revealed the resident had a Physician's Order dated 02/18/23 for an advanced directive to be a do not resuscitate comfort care arrest (DNRCC-A) code status. Review of the paper medical record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-31 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, and facility policy review, the facility failed to ensure one resident's (#72) tilt and space wheelchair was not misappropriated. This affected one of two residents reviewed for abuse. The facility census was 67. Findings include: Review of the medical record for Resident #72 revealed an initial admission date of 05/18/23 with diagnoses including Guillain-Barre syndrome, adult failure to thrive, congestive heart failure, hypertension, gastro-esophageal reflux disease, atrial fibrillation, obesity, urine retention, sleep apnea, quadriplegia, dysphagia, unstageable pressure ulcer to right heel. Review of the plan of care dated 05/18/23 revealed the resident was at risk for decline in activities of daily living (ADL) participation as evidenced by need for assistance with ADL, transfers, ambulation and toileting related to impaired mobility related to quadriplegia, Guillain Barre, failure to thrive, congestive heart failure, depression and atrial fibrillation. Interventions…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-31 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 observation, record review, interview, and facility policy review, the facility failed to develop a comprehensive plan of care in the area of indwelling urinary catheter and pain for two residents (#63 and #64). This affected two of 22 sampled residents. The facility census was 67. Findings Include: 1. Review of the medical record for Resident #64 revealed an initial admission date of 05/08/23 with diagnoses including diabetes mellitus, pressure ulcer sacral region, personal history of malignant neoplasm, malaise, non-Hodgkin lymphoma, lymph nodes of inguinal region and lower limb, carcinoma in bladder, lymphedema, generalized muscle weakness, hypertension, histoplasmosis, hyperlipidemia, morbid obesity, benign prostatic hyperplasia, gastro-esophageal reflux disease and neuromuscular dysfunction of bladder. Review of the admission nursing observation dated 05/08/23 revealed the resident was admitted to the facility with an indwelling urinary catheter. Review of the bowel and bladder assessment dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-31 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, staff interview, and policy review, the facility failed to ensure a resident's pressure ulcer was accurately assessed to identify the proper staging of the pressure ulcer. This affected one resident (#39) of four residents reviewed for pressure ulcers. Findings include: A review of Resident #39's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included vascular dementia, age-related physical debility, peripheral vascular disease, chronic kidney disease, diabetes mellitus, congestive heart failure, difficulty walking, and muscle weakness. A review of Resident #39's admission nursing assessment dated [DATE] revealed the resident was admitted to the facility with an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer was covered by slough and/ or eschar in the wound bed) to her coccyx that measured 9 centimeters (cm) by 7 cm. A review of Resident #39's quarterly Minimum Data Set (MDS) assessment dated [DATE]…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-31 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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, interview and facility policy review, the facility failed to ensure nebulizer medication delivery system was stored properly. This affected one of one resident (#58) reviewed for respiratory. The facility census was 67. Findings Include: Review of the medical record for Resident #58 revealed an initial admission date of 05/27/22 with the latest readmission of 07/15/23 with diagnoses including noninfective gastroenteritis and colitis, disorder of bone density, bacteremia, vascular dementia, chronic obstructive pulmonary disease (COPD), gastro-esophageal reflux disease, obstructive and uropathy, depression, anxiety disorder, epilepsy, osteoarthritis, spinal stenosis lumbar region, alcohol abuse, hypertension, neoplasm of unspecified behavior of endocrine glands and parts of nervous system, hyperlipidemia, bipolar disorder and hypothyroidism. Review of the plan of care dated 06/02/23 revealed the resident had an altered respiratory status/difficulty breathing related to COPD. Interventions included administer medications/puffers as ordered, monitor…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2021-10-07 · tag F0656 — failed to write and follow a full care plan — patternDevelop 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 observation, interview and record review the facility failed to develop and implement a comprehensive care plan to address the medical and physical needs of Residents #36, #39, #66 and #21. This affected four residents reviewed for care plans. The facility census was 63. Findings include: 1. Observation on 10/06/21 at 10:05 A.M. found Resident #36 participating in a group activity of devotions. Review of the medical record for Resident #36 revealed an admission date of 12/11/20. Diagnoses included Parkinson's disease, unspecified dementia,dysphagia and history of Covid 19. There was not an activity assessment completed on admission. Review of the activity participation documentation for 07/21, 08/21 and 09/21 revealed the resident participated in group activities when permitted due to pandemic guidelines and was provided one on one activities in her room. Review of the plan of care last updated 08/13/21 revealed no care plan for activities for Resident #36. The facility provided an activity assessment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-10-07 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and staff interview the facility failed to provide one resident (#52), who was dependent for activities of daily living (ADL) nail care. This affected one of three residents reviewed for ADL. Findings include: Review of Resident #52's medical record revealed an original admission date 12/22/16 with the latest readmission of 12/29/18. Diagnoses included dementia with behavioral disturbances, major depressive disorder, history of falling, hypertension, psychotic disorder with delusions, contracture of unspecified joint and allergic rhinitis. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had clear speech, rarely/never understood others, sometimes made herself understood, and had a severe cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of zero. The resident required extensive assist of two staff for personal hygiene, including nail care. Review of the plan of care dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-10-07 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of the facility policy related to falls, the facility failed to provide monitoring and care related to a hematoma and skin tears for Resident #39. This affected one of 16 residents reviewed. The facility census was 63. Findings inlcude: An observation on 10/04/21 at 3:26 P.M. of Resident #39 found a purple and green bruise above left eyebrow with a small skin tear in the center and a skin tear to left elbow. Resident #39 was unaware how she obtained the bruise and the skin tears. Review of the medical record for Resident #39 revealed an admission date of 08/17/21 with diagnoses including fracture of left femur and sacrum, Parkinson's disease and dementia. Review of the five day admission Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively impaired, and required two person extensive physical assistance with transfers and mobility. The resident had a history of falls. Review of the fall investigation dated 10/01/21 revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-10-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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, interview, and record review, the facility failed to maintain fall interventions for Resident #4. This affected one (#4) of four residents reviewed for falls. Findings include: Review of the medical record for Resident #4 revealed the resident was admitted on [DATE] with diagnoses including anxiety disorder, cerebral palsy, major depressive disorder, foot drop, chronic pain syndrome, dysphagia, and gastro-esophageal reflux disease. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderately impaired cognition and limited range of motion in the upper extremities on both sides. Review of the plan of care dated 11/14/20 revealed the resident was at risk for falls and potential injury related to poor decision making skills, unsteady gait, foot drop, muscle weakness, lack of coordination, weakness, and impaired balance. Interventions included assisting with transfers as needed, leaving urinal at bedside, educating and reminding the resident to move his…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-10-07 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, interview and facility policy review, the facility failed to ensure the enteral feeding bottle and tubing for Resident #36 was labeled with nurse initials, date and time initiated. This affected one resident receiving tube feeding. The facility census was 63. Findings include: An observation on 10/04/21 at 10:03 A.M. of Resident #36's enteral feeding bottle and tubing hanging from the administration pole and threaded through the pump, revealed no date and time the formula was initiated and the nurse did not initial. An interview on 10/04/21 at 10:15 A.M. with Licensed Practical Nurse (LPN) #13 confirmed the bottle of enteral feeding was not dated or initialed by the nurse along with the tubing. Review of the facility policy titled Enteral Tube feeding via Continuous Pump dated 11/18 revealed the facility did not follow the policy regarding labeling.
- Potential for harm · Dcited before2021-10-07 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to date and change oxygen tubing at appropriate intervals and document when 'as needed' oxygen was being used for Resident #21. This affected one resident (#21) of one reviewed for oxygen use. The facility identified 15 residents receiving oxygen. Findings include: Review of the medical record revealed Resident #21 had an admission date of 10/05/18 with diagnoses including chronic obstructive pulmonary disease, hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side, malignant neoplasm of ascending colon, chronic kidney disease stage three, major depressive disorder, dysphagia, chronic respiratory failure with hypoxia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed the resident had intact cognition. Review of the physician's orders for September and October 2021 revealed an order for oxygen four liters per minute as needed for shortness of breath. There…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-10-07 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to address one resident's (#24) pharmacy recommendation in a timely manner. Additionally the facility also failed to carry out one resident's (#52) pharmacy recommendation when addressed by the physician. This affected two of five residents reviewed for unnecessary medications. Findings Include: 1. Review of Resident #24's medical record revealed an original admission date of 04/03/17 with the latest readmission of 03/20/20. Diagnoses included chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure, chronic bronchitis, emphysema, bipolar disorder, paranoid personality disorder, dysphagia, low back pain, anxiety disorder, gastroesophageal reflux disease (GERD), chronic pain syndrome, insomnia, vitamin D deficiency, benign prostatic hyperplasia, constipation, hypertension, osteoarthritis, major depressive disorder and nontoxic goiter. Review of the plan of care dated 02/04/20 revealed the resident used anti-anxiety…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-10-07 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure one resident's (#52) Claritin (an antihistamine medication) was discontinued as physician ordered. This affected one of five residents reviewed for unnecessary medications. Findings include: Review of Resident #52's medical record revealed an original admission date 12/22/16 with the latest readmission of 12/29/18. Diagnoses included dementia with behavioral disturbances, major depressive disorder, history of falling, hypertension, psychotic disorder with delusions, contracture of unspecified joint and allergic rhinitis. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had clear speech, rarely/never understood others, sometimes made herself understood and had a severe cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of zero. Review of the pharmacy recommendation dated 06/26/20 revealed the pharmacist recommended the medication Claritin 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.
- Potential for harm · D2021-10-07 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview the facility failed to serve food in a sanitary manner, when touching ready to eat food with soiled gloves for two residents (#13 and #43). The facility identified 62 residents who consumed food from the kitchen. The facility census was 63. Findings include: On 10/06/21 at 11:30 A.M. observation of the lunch service revealed Dietary Aide #121 was serving the meal. She was observed at 11:30 A.M. washing her hands and putting on a pair of gloves. At 11:43 A.M., 11:44, A.M., and 12:10 P.M. she was observed touching and adjusting her face mask and at 12:05 P.M. she was observed putting her right hand on her scrubs while wearing the same pair of gloves. Observation at 11:54 A.M. revealed Dietary Aide #121 grabbing a hot dog bun out of a bag for Resident #43 and at 12:30 P.M. she grabbed two hot dog buns for Resident #13. She did not change gloves or wash hands before touching the food. Interview at 12:40 A.M. with Dietary Aide #121 confirmed she had touched her face mask and touched food without removing her gloves and washing her hands. It 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to AYDEN HEALTHCARE — 11 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 2.1 | +1.9 vs chain |
| Health inspection | 4 of 5 | 1.9 | +2.1 vs chain |
| Staffing | 2 of 5 | 1.8 | +0.2 vs chain |
| Quality measures | 4 of 5 | 4.5 | -0.5 vs chain |
The other 10 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| KAZARNOVSKY, SOLOMON | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 50% | since 12/31/2021 |
| STEIN, ABBA | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 50% | since 12/31/2021 |
| CUSNER, ADAM | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/27/2025 |
| DEGYANSKY, JEFFREY | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2020 |
| GOLDISH, ELIEZER | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/09/2023 |
CMS files one row per role, so the 16 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.7M 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
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OH
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Ohio Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 365393. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-29, 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.