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Lanfair Center For Rehab & Nsg Care INC

1590 Chartwell Street, Lancaster, OH 43130 · For profit - Corporation · 84 certified beds · (740) 687-5100 Medicare & Medicaid certified

Call the home — (740) 687-5100 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0605) — cited May 2025Resident-funds citations (F0568, F0569)
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has citations for mishandling residents’ money or property (F0568, F0569)
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score

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

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

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

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

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
(740) 687-6386 · Call to confirm hours
Pharmacy
Kroger1.7 mi
401 N Ewing St · (740) 654-1019 · Call to confirm hours
Grocery
506 N High St · (740) 777-2993 · Call to confirm hours
Park
1451 Huffer Ave · Typically dawn to dusk
Place of worship
1950 Pleasantville Rd · (740) 687-1776

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

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 5 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 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 increased2.6%5.3%15.4%better than state — see note marked double-dagger below the table
Long-stay residents who lose too much weight6.9%6.2%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.2%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection1.8%0.4%2.0%typical
Long-stay residents with depressive symptoms37.4%30.1%6.5%worse 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 injury5.8%3.2%3.3%worse
Long-stay residents whose ability to walk worsened4.9%6.1%16.1%better than state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication35.6%25.5%18.9%worse
Long-stay residents given the seasonal flu vaccine96.6%94.5%95.3%typical
Long-stay residents with pressure ulcers0.8%3.4%4.7%better
Long-stay residents with worsening bladder/bowel control17.6%21.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table6.9%8.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.3%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine90.1%75.6%79.4%better
Short-stay residents rehospitalized after admission18.1%24.9%22.6%better
Short-stay residents with an outpatient ER visit12.0%12.9%12.0%typical

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.

66.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 288 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

66.4%U.S. median 51.5%
Got home and stayed home
12.1%U.S. median 10.7%
Went back to hospital
47.0%U.S. median 56.6%
Met the expected recovery
0.39U.S. median 0.31
Therapy hours / resident / day
0.18hours / resident / day
Physical therapy
0.17hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 47.0% 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 115 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 0.39 therapist hours per resident per day in 2026Q1 — more than 68% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 11% 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 SNF66.4%CMS range 62.4–71.951.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.1%CMS range 8.3–15.410.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge47.0%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 discharge46.1%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 discharge50.4%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.7%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%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 hospitalization6.4%CMS range 3.7–9.57.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.781.02Oct 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

0.84
RN hours/ resident / day
0.83
LPN hours/ resident / day
2.16
Aide hours/ resident / day
3.83
Total nurse hours/ resident / day
0.42
RN hoursweekends
45.5%
Total nursing turnover
15.8%
RN turnover

How full it usually is: this home is certified for 84 beds and averages 79.7 residents a day — about 95% occupied, or roughly 4 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 3.83 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.84 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.16 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 3.23 hrs/resident/day on weekends vs 4.06 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 1.01 to 0.42 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 46% is about the same as the national median of 45%.

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

Inspection trend

8
deficiencies at the latest standard inspection (2025-05-08)
6
at the previous standard inspection (2024-02-26)

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.

23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.

  • Potential for harm · Dcited before2025-06-11 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and staff interview, the facility failed to ensure a resident with continued weight loss was provided with nutritional supplements as ordered. This affected one resident (#5) of three residents reviewed for weight loss. The facility census was 82. Findings include: During the annual survey completed 05/08/25, a deficiency was issued related to Resident #5's weight loss. Review of the medical record for Resident #5 on 06/10/25 revealed an admission date of 07/25/24 and diagnoses including dementia, dysphagia, and acute kidney failure. Review of physician's orders revealed an order on 12/24/24 for a pureed diet, nectar thick liquids, and four ounces of Gelato (an ice cream type nutritional supplement containing 260 calories) with meals. Review of the plan of care started on 07/29/24 revealed Resident #5 was at nutritional risk. The goal was for no significant weight change. The interventions included Gelato at all meals (beginning 12/24/24). Observations on 06/10/25 at 11:58 A.M. revealed Resident #5's lunch tray was taken to his room. It…

    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 before2025-06-11 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, facility policy review and review of The Center for Clinical Standards and Quality QSO-24-08-NH memo, the facility failed to follow enhanced barrier precautions (EBP) during wound care. This affected one resident (#61) of one resident observed for wound care. The facility census was 82. Findings included: During the annual survey completed 05/08/25, a deficiency was issued related to the facility's failure to implement EBP during wound care. Review of the medical record for Resident #61 revealed an admission date of 04/25/25 and diagnoses including fracture of right lower leg with orthopedic surgery and sepsis with surgical wound infection. Review of hospital records revealed the resident was admitted with severe sepsis secondary to a right ankle wound infection. The resident had surgery on the right ankle on 04/15/25 and 04/22/25. The surgical culture showed Enterococcus facialis. The resident then admitted to the facility on [DATE]. The resident had physician'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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-05-08 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and facility policy review, the facility failed to label and store food in a safe manner. This affected all the residents residing in the facility, except Resident #69 who was nothing by mouth. The facility census was 82. Findings include: Observation of the walk-in refrigerator on 05/05/25 at 9:30 A.M., revealed an undated jar of minced garlic that was more than half empty, three deli sandwiches, open and undated, and a package of deli meat, open and undated. Interview on 05/05/25 at 9:32 A.M. with Dietary Manager (DM) #194, confirmed three undated items in the walk-in refrigerator. DM #194 dated minced garlic at the time of discovery and discarded the deli sandwiches and package of deli meat. Observation of the pantry on 05/05/25 at 9:35 A.M., revealed, an undated half of a bottle of orange concentrated syrup and a large undated open bag of crackers. Interview on 05/05/25 at 9:40 A.M. with DM #194, confirmed undated items in the pantry. DM #194 dated orange concentrated syrup at time of discovery. She also discarded the undated bag of crackers.…

    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 · D2025-05-08 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    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 medical record review the facility failed to ensure Resident #51 had appropriate diagnosis for psychotropic's and failed to monitor Resident #51's behaviors. This affected one residents (#51) of five residents reviewed for unnecessary medications. The facility census was 82. Findings include: Review of Resident #51's medical record revealed an admission date of 03/16/23 with diagnoses including dementia with psychotic disturbance, cognitive communication deficit, anxiety disorder, major depressive disorder, metabolic encephalopathy, and hypertension. Review of Resident #51's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she was rarely or never understood. Review of Resident #51's plan of care dated 03/17/23 revealed the resident received psychotropic medications including antidepressants, antianxiety medications, and antipsychotics related to her diagnosis of dementia with psychotic disturbance. Interventions included observing for side effects,…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-08 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and medical record review the facility failed to ensure the state was notified of a change in mental disease for Resident #28 and #51. This affected two residents (#28 and #51) of two residents reviewed for Preadmission Screening/Resident Review Identification Screen (PASARR). The facility census was 82. Findings include: 1. Review of Resident #28's medical record revealed an admission date of 02/01/17 with diagnoses including dementia, epilepsy, bipolar disorder, other psychotic disorder, and dysphagia. In 2022 diagnoses of schizoaffective disorder and anxiety disorder were added and on 01/14/23 a diagnosis of major depressive disorder was added. Review of Resident #28's medical record revealed the last PASSAR was submitted 08/16/18 and indicated she had a mood disorder and insomnia. Interview on 05/06/15 at 10:40 A.M. with Regional Director of Social Services and Activities #229 verified a PASSAR was not completed when Resident #28's diagnoses changed and should have been. 2. Review of Resident #51's medical record revealed an admission date of 03/16/23 with…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-08 · 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 observation, medical record review, interviews and facility policy review, the facility failed to develop a comprehensive plan of care for two residents (#5 and #184) in the area of swallowing strategies and c-pap use. This affected two residents (#5 and #184) of 23 sampled residents. The facility was 82. Findings Include: 1. Review of the medical record for Resident #5 revealed an initial admission date of 07/25/24 with the diagnoses including but not limited to cerebrovascular disease, fungal endocarditis, choledocholithiasis, Alzheimer's disease, hypothyroidism, obstructive and reflux uropathy, dysphagia, hyperlipidemia, seizures, chronic kidney disease, retention of urine, benign prostatic hyperplasia, abdominal aortic aneurysm, gastro-esophageal reflux disease and dementia. Review of the resident's hospital Discharge summary dated [DATE] revealed the resident's diet order on discharge was to resume his home diet. Review of the Modified Barium Swallow (MBS) results dated 07/22/24 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-08 · 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 observation, interview and medical record review, the facility failed to provide daily wound care as ordered for Resident #182. This affected one (Resident #182) out of one resident reviewed for skin impairment. The facility census was 82. Findings include: Review of Resident #182's medical record revealed she was admitted on [DATE] with diagnoses that included multiple fractures of the pelvis, falls, pustular psoriasis, diabetes mellitus type 2, moderate protein malnutrition, HLD and low back pain. Review of Resident # 182's physicians orders dated 05/01/25, revealed an order for SilvaSorb gel; cleanse right dorsal foot with IHWC (in house wound cleanser), pat dry, apply thin layer SilvaSorb and cover with foam dressing daily and as needed, and an order dated 05/02/25, to cleanse left lower extremity with IHWC (in house wound cleanser), pat dry, apply thin layer SilvaSorb to open wound bed, cover with non-adherent and wrap with kerlix daily and prn. Review of Resident # 182's care plan dated 05/03/25,…

    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 before2025-05-08 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of the medical record for Resident #62 revealed an admission date of 03/19/25, with diagnoses including urinary tract infection, moderate protein-calorie malnutrition, abnormal weight loss, and type two diabetes mellitus. Review of weight record for Resident #62 revealed on 03/17/2025, the resident weighed 215.6 lbs. On 04/14/2025, the resident weighed 190.8 lbs, which reflects an 11.50% loss. Review of care plan dated 03/20/25 revealed the resident is at risk for altered nutrition related to urinary tract infection, candidal sepsis, impaired skin integrity, diabetes, edema, obesity, and the need for a therapeutic diet. The resident's care approaches included offering menu alternatives as needed, honoring food preferences, monitoring weekly weights for four weeks then monthly if stable, and notifying the registered dietitian and physician if there is a significant weight change over five percent. Review of minimum data set (MDS) 3.0 assessment completed on 03/26/25 revealed a Brief Interview for Mental…

    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 · D2025-05-08 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, review of medical record, and review of facility policy the facility failed to have physician orders in place for Resident #184's Bilevel Positive Airway Pressure (BiPAP) and failed to ensure oxygen orders were followed and oxygen administration was documented for Resident #33. This affected two residents (#33 and #184) of three residents reviewed for respiratory care. The facility census was 82. 1. Review of Resident #33's medical record revealed an admission date of 04/15/22 with diagnoses including chronic obstructive pulmonary disease, moderate protein- calorie malnutrition, unspecified dementia, generalized anxiety disorder, dysphagia, major depressive disorder, and altered mental status. Review of Resident #33's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed resident was rarely or never understood. He received oxygen therapy. Review of Resident #33's physician order dated 09/24/23 revealed an order for continuous oxygen at two liters via a nasal…

    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 · D2025-05-08 · 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 interview and medical record review the facility failed to ensure the physician gave a clear reason why a pharmacy recommended gradual dose reduction (GDR) was not performed on residents with psychotropic's. This affected two residents (#28 and #51) of five residents reviewed for unnecessary medications. The facility census was 82. Findings include: 1. Review of Resident #51's medical record revealed an admission date of 03/16/23 with diagnoses including dementia with psychotic disturbance, cognitive communication deficit, anxiety disorder, major depressive disorder, metabolic encephalopathy, and hypertension. Review of Resident #51's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she was rarely or never understood. Review of Resident #51's pharmacy recommendation dated 09/19/24 revealed the pharmacist recommended trialing a decrease of Quetiapine (an antipsychotic) to 25 milligrams (mg) every other day for seven days due to no documented behaviors on MDS and a dementia diagnosis.…

    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
Show the remaining 13 citations
  • Potential for harm · F2024-11-19 · tag F0908 — failed to keep essential equipment working — widespread
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and review of a repair bid from an outside vendor, the facility failed to maintain the dish machine in the kitchen in safe operating condition. This had the potential to affect all of the residents residing in the facility. The facility census was 74 residents. Findings include: Observation of the kitchen on [DATE] at 9:21 A.M. revealed the dish machine had a bright, red sign posted on the front telling staff not to remove the towels that were placed at the base of the machine where it met with the sink, and that any staff who removed the towels, would be responsible for cleaning the water out of the dish machine. Interview on [DATE] at 9:21 A.M. with Dietary Coordinator (DC) #133 confirmed the dish machine was broken, and kitchen staff were required to keep towels in place at the base of the machine where it met with the sink in order to prevent water from backflowing into it when the water sprayers were used. DC #133 confirmed that if the towels were removed, staff would…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-11-19 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and review of the facility policy, the facility failed to ensure staff performed proper hand hygiene during meal service. This affected four (Residents #34, #35, #36, #37) of 44 residents residing on the Pleasantville Unit. The facility census was 74 residents. Findings include: Observation on 11/19/24 at 11:48 A.M. of meal service revealed Certified Nursing Assistant (CNA) #112 was wearing gloves while passing meal trays. CNA #112 delivered trays to Residents #34, #35, #36, and #37 in their rooms and did not remove gloves or perform hand hygiene between residents. Interview on 11/19/24 at 11:54 A.M. with Dietary Coordinator (DC) #133 confirmed that DC #133 was present and had participated in meal service on the Pleasantville Unit and had observed CNA #112 wearing the same pair of gloves throughout the tray pass on the Pleasantville Unit. DC #133 also confirmed that CNA #112 had not followed the facility's infection control policy and procedure by entering multiple resident rooms without changing gloves and/or performing proper hand hygiene.…

    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 before2024-11-19 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, resident interview, and review of the facility policy, the facility failed to provide residents with a dignified dining experience by serving resident meals on Styrofoam tableware and cups with plastic cutlery. This affected three (Residents #30, #42, and #73) of three residents observed for meal service and had the potential to affect all of the residents residing in the facility. The facility census was 74 residents. Findings include: Observation on 11/19/24 at 9:16 A.M. of random residents on the memory care unit revealed one resident who had a Styrofoam cup with a plastic spoon in it, a Styrofoam plate, and a Styrofoam bowl sitting on the table in front of her. No staff were seen in the vicinity at the time of this observation. Observation on 11/19/24 at 9:26 A.M. revealed a large box of three-compartment aluminum trays, and stacks of Styrofoam plates, cups and bowls in the tray line/meal preparation area of the kitchen. Interview on 11/19/24 at 9:26 A.M. with Dietary Coordinator (DC) 133 confirmed that the dish machine in the kitchen 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
  • Potential for harm · F2024-02-26 · tag F0868 — widespread
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of quality assurance and performance improvement (QAPI) meeting sign in sheets, staff interview, and facility policy review, the facility failed to ensure the infection preventionist attended the QAPI meetings. This had the potential to affect all 80 residents in the facility. The census was 80. Findings include: Review of the facility QAPI meeting sign in sheets, dated March 2023 to January 2024, revealed Registered Nurse (RN) Supervisor #311, who was the facility's only infection preventionist, did not attend any of the QAPI meetings. Interview with RN Supervisor #311 on 02/22/24 at 4:07 P.M. confirmed she was the only infection preventionist in the facility. She confirmed the Director of Nursing (DON) attends the QAPI meetings with the infection reports and documentation to report to the committee however RN Supervisor #311 does not. Interview with the DON on 02/26/24 at 1:46 P.M. confirmed he was not an infection preventionist but would be going through the training soon. Interview with the Administrator on 02/26/24 at 3:25 P.M. confirmed RN Supervisor #311 did…

    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 · Fcited before2024-02-26 · 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 2. Review of the medical record for Resident #11 revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including vascular dementia, weakness, anxiety, heart disease and unspecified urinary incontinence. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/14/23, revealed Resident #11 had severely impaired cognition, required staff assistance for activities of daily living (ADL) tasks and was always incontinent of urine and bowel. Review of Resident #11's ADL care plan, dated 12/29/22, revealed Resident #11 required assistance from staff for incontinence care. Further review of the incontinence care plan, dated 09/02/21, revealed Resident #11 required staff to assist with changing clothing, incontinence briefs, and linens as needed due to soiling. Observation on 02/26/24 at 9:49 A.M. revealed perineal incontinence care for Resident #11 was being completed by State Tested Nursing Assistants (STNAs) #280 and #334. STNA #280 and STNA #334 sanitized their hands and donned gloves.…

    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 · Ecited before2024-02-26 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and facility policy review, the facility failed to serve residents in a dignified manner during the dinner meal service. The deficient practice affected eight residents (Residents #6, #11, #18, #24, #32, #39, #50, and #54) of 14 residents who served meals in the dining room on the memory care unit (Speret Hall). The facility census was 80. Findings include: Observation on 02/21/24 at 5:37 P.M. revealed 14 residents were sitting at five different tables in the dining room area on the locked memory care unit for dinner meal service. Five residents (Residents #6, #24, #32, #50, and #54) did not have a beverage in front of them. The other nine residents did have a beverage. Interview on 02/21/24 at 5:40 P.M. with State Tested Nurse Aide (STNA) #280 revealed the dinner meal was typically arrived on the memory care unit between 5:30 P.M. and 6:00 P.M. Observation on 02/21/24 at 6:04 P.M. revealed the dinner meal had not arrived on the memory care unit yet. At 6:05 P.M., a cart with plates and utensils was delivered to the memory care unit. At 6:20…

    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 · E2024-02-26 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on resident interview, observation, staff interview, and facility policy review, the facility failed to maintain air temperature at a comfortable level in the small dining room. This had the potential to affect 54 (Residents #2, #3, #6, #8, #9, #10, #12, #13, #15, #16, #20, #22, #23, #27, #28, #29, #30, #31, #34, #37, #40, #41, #43, #44, #46, #47, #48, #49, #53, #56, #57, #58, #59, #62, #68, #69, #71, #72, #73, #74, #77, #134, #136, #137, #139, #140, #141, #142, #284, #285, #334, #335, #336, and #337) of 80 residents in the facility who could go to the small dining room. The census was 80. Findings include: Interview with Resident #23 and Resident #30 on 02/21/24 at 9:28 A.M. revealed they don't like to sit in the small dining room for meals because it was very cold. They revealed it had been cold in the small dining room for quite some time. Observation on 02/21/24 at 3:21 P.M. revealed the small dining room thermostat read 68 degrees Fahrenheit. Observation on 02/26/24 at 8:30 A.M. revealed the temperature in the small dining room was 68 degrees Fahrenheit. Observation on…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-26 · tag F0881 — failed to use antibiotics responsibly — pattern
    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 Monthly Infection Tracking Logs, staff interviews, and facility policy review, the facility failed to ensure the appropriate use of antibiotics according to their antibiotic stewardship program (ASP). This affected six (Residents #7, #40, #42, #51, #58, and #253) out of 80 residents in the facility. The facility census was 80. Findings include: Review of the Monthly Infection Tracking Log, dated October 2023, revealed Resident #51 had a healthcare associated (HA) urinary tract infection (UTI). A McGeer's criteria (criteria used to identify infections) was completed and the criteria for a UTI was not met. There was no culture completed. Resident #51 received Macrobid (an antibiotic) from 09/29/23 to 10/01/23. Resident #7 received Macrodantin (an oral antibiotic) as a UTI prophylactic with a start date on 03/23/23 and no stop date indicated. Resident #58 had a HA UTI and kidney stones noted and did not meet McGeer's criteria for an infection. The resident received Keflex (an oral antibiotic) with a start date of 07/14/23 and no stop date. Review of the ASP Monthly…

    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 · D2024-02-26 · tag F0569 — isolated
    Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
    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 insurance records, review of financial records, and staff interview, the facility failed to provide spend down notices to residents and/or resident representatives when their personal funds account was within $200 of the Medicaid personal funds limit. This affected two (Residents #2 and #20) of five residents reviewed for personal funds accounts. The census was 80. Findings include: 1. Review of Resident #2's medical record revealed Resident #2 was admitted to the facility on [DATE]. Resident #2's diagnoses included but were not limited to cerebrovascular disease, hemiplegia, chronic ischemic heart disease, and heart failure. Review of Resident #2's Minimum Data Set (MDS) assessment, dated 12/31/23, revealed Resident #2 had a mild cognitive impairment. Review of Resident #2's insurance records revealed she had Medicaid as insurance. Review of Resident #2's financial records, dated 12/31/22 to 12/29/23, revealed her balance for her person funds account was within the $200…

    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 · D2023-08-15 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interview, and policy review, the facility failed to ensure residents had privacy during personal care. This affected one of three residents observed for medication administration (Resident #16). The facility census was 78. Findings include: Observations on 08/15/23 at 7:55 A.M. revealed Licensed Practical Nurse (LPN) #80 to administer a pain patch for Resident #16. LPN #80 exposed the resident's upper thigh/hip area while she was lying in her bed and placed the pain patch to the upper thigh area. LPN #80 did not close the door to the room and did not close the privacy curtain around the bed. Two different staff persons were observed to walk by the door to the room when the resident was exposed, with the door open. Interview with LPN #80 on 08/15/23 at 8:10 A.M. confirmed she did not provide privacy for Resident #16 and should have. The surveyor requested the facility policy on privacy. The Administrator provided a policy dated 10/16 and titled Resident Rights. It stated residents are entitled to exercise their rights and privileges to the fullest extent…

    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 · Dcited before2023-08-15 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review and staff interview, the facility failed to ensure a resident received treatment and care as it was ordered by the physician. This affected one of three sampled residents (Resident #31). The facility census was 78. Findings include: Review of the medical record for Resident #31 revealed an admission date of 06/04/21 and diagnoses including retention of urine, acute kidney failure, overactive bladder, and urinary tract infections. Review of a physician appointment communication sheet dated 05/25/23 revealed a physician's order for a hormone cream (Estradiol) 01%, one half gram at bedtime on Monday, Wednesday, and Friday. Review of a nurse's progress note on 05/25/23 at 9:17 A.M. revealed Resident #31 returned from appointment at this time. New order to start resident on Estradiol cream one half gram at bedtime on Monday, Wednesday, and Friday. However, review of the May 2023 medication administration record (MAR) revealed no evidence the hormone cream was given in May 2023. Record review revealed a physician's order on 06/03/23 by the facility nurse…

    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 · Ecited before2022-04-04 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, facility policy and procedure review, review of guidance from the Centers for Disease Control (CDC) and interview the facility failed to maintain adequate and acceptable infection control practices during medication administration for Resident #13 and for Resident #232 who was in isolation to prevent the spread of infection including COVID-19. Observations during medication administration revealed medications were handled by the nurse with bare hands when administering to Resident #13 and two State Tested Nursing Assistants (STNAs), STNA #43 and STNA #58 were observed to enter Resident #232's room, a resident who was in droplet isolation precautions for COVID-19 without applying all required personal protective equipment (PPE) including gown and gloves. This affected two residents (#13 and #232) and had the potential to affect all facility residents excluding 19 residents residing on the secured memory care unit which had dedicated staff. The facility census was 79. Findings Include: 1. Review of Resident #232's medical record revealed 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-04-04 · tag F0568 — isolated
    Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
    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, financial record review, staff interview and facility policy and procedure review the facility failed to maintain accurate and timely accounting practices for services received and charged to Resident #3. This affected one resident (#3) of six residents whose financial records were reviewed. Findings Include: Record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, sepsis, type II diabetes mellitus, chronic kidney disease, osteoarthritis, hypertension, major depressive disorder, anxiety disorder, psychosis, dementia, mood disorder, dysphagia and cognitive communication deficit. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 03/11/22 revealed the resident was cognitively impaired. Review of Resident #3's financial records, dated 03/01/21 to 12/31/21 revealed the following beauty shop invoices and subsequent charges documented within the quarterly bank statements (the facility reported there could be up to 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.

    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.

Part of a chain

This home belongs to ALTERCARE — 22 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 53.3+0.7 vs chain
Health inspection 3 of 52.7+0.3 vs chain
Staffing 3 of 52.3+0.7 vs chain
Quality measures 5 of 54.8+0.2 vs chain
The other 21 homes this chain runs (chain average 3.3★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
TSG NURSING CENTERS, INCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 12/13/2002
GERALD F SCHROER DYNASTY TR UA 12312009 FBO ANDREW M SCHROEROrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/15/2015
GERALD F SCHROER DYNASTY TR UA 12312009 FBO GERALD F SCHROER JROrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/15/2015
GERALD F SCHROER DYNASTY TR UA 12312009 FBO MATTHEW SCHROEROrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/15/2015
GERALD F SCHROER DYNASTY TR UA 12312009 MARGARET S GOODMANOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/15/2015
SUSANNE SCHROER DYNASTY TRUST U/AOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/15/2015
THE SCHROER GROUP, INC.Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 10/01/2001
MOCK, DOUGLASIndividualW-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR; CORPORATE OFFICERsince 09/20/2021
FILM, GEORGEIndividualCORPORATE OFFICERsince 07/01/2019
GOODMAN, JOHNIndividualCORPORATE OFFICERsince 05/15/2003
LOGAN, JUSTINIndividualCORPORATE OFFICERsince 06/01/2022
NUTTER, ORIANIndividualCORPORATE OFFICERsince 10/01/2021
ALTERCARE OF OHIO, INCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 06/30/2000

CMS files one row per role, so the 15 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted.

8 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$9.7M
Net patient revenuemost recent cost report
+6.1%
Operating marginrevenue minus expenses
$1.1M
Related-party expense12% of expenses
Who pays — share of resident-days
Medicaid 50%Medicare 14%Other / private 36%

This home reported $1.1M paid to related parties — landlords or management companies under common ownership — equal to about 12% 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

$321per resident / day
operating cost
$9,766per month
≈ monthly operating cost
$342per 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 366215. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-08, 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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