Main Street Terrace Care Center
1318 E Main Street, Lancaster, OH 43130 · For profit - Corporation · 50 certified beds · (740) 653-8767 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (33% vs 45% nationally) — better care continuity
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (30) — 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 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
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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 | 4 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 | 6.2% | 5.3% | 15.4% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 3.8% | 6.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.2% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.4% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 3.2% | 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 | 3.7% | 3.2% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 5.6% | 6.1% | 16.1% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 20.9% | 25.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 89.4% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 0.9% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 27.7% | 21.4% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 6.9% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 82.1% | 75.6% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 20.8% | 24.9% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 9.6% | 12.9% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 0.41 | 1.73 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.35 | 1.80 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
47.2% 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 70 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 33.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 39 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 0.22 therapist hours per resident per day in 2026Q1 — more than 26% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 6% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| 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 | 47.2%CMS range 35.9–56.8 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.3%CMS range 7.9–15.4 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 33.3% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 28.2% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 33.3% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 97.8% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.7%CMS range 4.1–13.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.19 | 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 50 beds and averages 46.4 residents a day — about 93% 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 3.71 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.54 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.31 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 3.41 hrs/resident/day on weekends vs 3.84 on weekdays — 11% thinner on weekends. RN hours go from 0.60 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 33% is below 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 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.
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.
30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.
- Actual harm · Gcited before2024-10-28 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of the facility policy, review of information from the National Pressure Ulcer Advisory Panel (NPUAP) and interview, the facility failed to develop and implement a comprehensive and individualized pressure ulcer program to prevent the deterioration of a pressure ulcer for Resident #45. Actual Harm occurred on 10/03/24 when Resident #45, who was admitted to the facility with a Stage III (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present) sacral pressure ulcer was assessed to have an unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcer with the presence of slough and necrotic tissue to the area. The deterioration of the pressure ulcer was a result of the facility not implementing effective and timely treatment. This affected one…
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 · F2025-12-31 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 review of service report and email, the facility failed to maintain a clean stove hood in the kitchen. This had the potential to affect all 45 residents residing in the facility. The facility census was 45.Findings include:Observation of the kitchen on 12/30/25 at 10:20 A.M. revealed the kitchen hood above the stove to be dusty. Observation of the inspection and cleaning sticker on the kitchen hood revealed it was last cleaned 08/27/25 and due again after 90 days. Interview with the Dietary Manager on 12/30/25 at 10:22 A.M. confirmed the kitchen hood above the stove was dusty and should have been cleaned and confirmed the kitchen hood was supposed to be cleaned every 90 days. The Dietary Manager further confirmed having paperwork to show inspections were completed but reported they were not the most current reports. Review of the service report revealed a date of 02/13/25. Review of an email dated 02/28/25 from Silco Fire and Security revealed the next inspection was scheduled for 03/06/25. There were no further service reports or documentation…
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 before2025-12-31 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on closed record review, interview, and review of the facility's Beneficiary Notices, the facility failed to provide notification to residents and/or representative within 48 hours. This affected one resident, (#53), of three residents reviewed for Beneficiary Notification. The facility census was 45.Findings include:Review of the closed record for Resident #53 revealed an admission date of 08/23/25 and discharge date of 09/13/25. Diagnoses for Resident #53 included, but were not limited to, dementia (9/9/25), obstructive and reflux uropathy (8/26/25), GERD (8/23/25), osteoarthritis (8/23/25), HTN (8/23/25), anxiety disorder (8/23/25), adult failure to thrive (8/23/25), anemia (8/23/25), altered mental status (8/23/25), pain (8/23/25), tachycardia (8/23/25), atherosclerotic heart disease (8/23/25), and obesity (8/23/25). BIMS for Resident #53, according to Minimum Data Set (MDS) section C, signed 09/15/25, was 11. Review of the facility's Beneficiary Notice revealed the notice for Resident #53 had an effective date of 09/11/25 for coverage to end. Further review 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 · D2025-12-31 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, interview, review of a facility Self-Reported Incident (SRI), review of December 2025 In-service Sign Off, and review of the facility's Resident Safety policy, the facility failed to complete resident abuse in-service reeducation for an agency aide involved in an abuse allegation following the investigation. This affected one, (#06), of three residents reviewed for abuse. The facility census was 45.Findings include:Review of Resident #06's record revealed an admission date of 11/11/25 with diagnoses of, but not limited to, muscle weakness (11/11/25), difficulty in walking (11/11/25), other lack of coordination (11/11/25), cognitive communication deficit (11/11/25), low back pain (11/11/25), chronic pain syndrome (11/11/25), weakness (11/7/25). Review of Resident #06's Minimum Data Set (MDS) signed 11/21/25 revealed a Brief Interview for Mental Status (BIMS) score of 14. Interview with Resident #06 on 12/29/25 at 1:50 P.M. revealed the resident had an incident with an aide, believed to have occurred a few weeks ago. Resident #06 reported the aide had been…
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 · D2025-12-31 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure preadmission screening resident review (PASARR)'s were up dated with additional mental illness diagnoses. This affected three residents (#5, #8 and #23) of three residents reviewed for PASARR. The census was 45.Findings include:1. Review of Resident #5's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included dementia, diabetes, metabolic encephalopathy, emphysema, chronic respiratory failure, psychosis, depression, and anxiety disorder. Review of the quarterly MDS dated [DATE] revealed his cognition was not intact. He required set up or clean up assistance with eating, oral hygiene, dependent on toileting, personal hygiene, substantial/maximal assistance for shower/bathing and partial/maximal assistance with turning and repositioning. Always incontinent of bladder and always continent of bowel. Further review revealed a PASARR completed on 08/17/23. On 12/24/24 Resident #5 received a new diagnosis of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-31 · 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 record review, review of care plan, and interview, the facility failed to ensure monitoring was in place for the side effects of opioid medications. This affected one (#4) of five residents reviewed for unnecessary medications. The facility census was 45. Findings include:Record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, fracture of right fibula and fracture of shaft of left femur. Review of a care plan dated 06/18/25 revealed no evidence of monitoring for side effects of taking opioid medications. Review of an order dated 10/30/25 revealed Resident #4 had hydrocodone-acetaminophen oral tablet 5-325 milligrams (mg) one tablet by mouth every four hours as needed for pain. There was no evidence of an order for monitoring side effects for opioid medications. Review of a minimum data set (MDS) assessment dated [DATE] revealed Resident #4's cognition remained intact, she had no behaviors, she had frequent pain of two, and she took 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.
- Potential for harm · Dcited before2025-12-31 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents were provided a care conference quarterly. This affected one resident (#7) of one resident reviewed for care conferences. The facility census was 45. Findings include:Record review revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, asthma, and depression. Review of the medical record revealed there had been no quarterly care conferences since 01/21/25. Review of minimum data set (MDS) assessment records revealed Resident #7 had MDS' completed on 03/26/25, 06/26/25, and 09/26/25. Review of a MDS dated [DATE] revealed Resident #7's cognition remained intact and she had no behaviors. Interview on 12/29/25 at 1:30 P.M. with Resident #7 revealed she could not recall having a care conference. Interview on 12/30/25 at 1:21 P.M. with Social Worker (SW) #201 revealed the Director of Nursing (DON) is who usually documents care conferences. SW #201 stated care conference should be completed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-31 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and staff interview, the facility failed to ensure resident nebulizer equipment was stored in a safe and sanitary manner and not laying directly on their bed surface or bedside tablet. This affected two residents (Resident #01 and #23) of the three residents reviewed for oxygen. The facility census was 45. Findings include:1. Review of the medical record for Resident #01 revealed an admission date of 11/22/22 with a re-entry date of 12/05/23. Diagnoses included chronic obstructive sleep apnea, pulmonary disease, respiratory disorder, and malignant neoplasm of the pancreas and left lower right lung lobe. Review of Resident #01's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating an intact cognition for daily decision-making abilities. Review of Resident #01's current physician orders revealed an order for Albuterol Sulfate inhalation 2.5 milligram (mg) per every 3 milliliter…
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 · D2025-12-31 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and observation the facility failed to ensure residents' pulse was monitored prior to administration of medication as well as pain medication had parameters in place related to the numeric pain scale. This affected two residents (#12 and #4) of the five residents reviewed for unnecessary medication. The facility census was 45. Findings include: 1.Review of the medical record for Resident #12 revealed an admission date of 02/22/21. Diagnoses included anxiety disorder, acute respiratory failure, hypertension, and Alzheimer's disease. Review of Resident #12's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 03 out of 15 indicating a severely impaired cognition for daily decision-making abilities. Review of Resident #12's current physician orders revealed an order for Atenolol (beta blocker) oral tablet 50 milligrams (mg) give one tablet in the morning. Hold for pulse less than 55. Review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-31 · tag F0804 — failed to serve food at safe, palatable temperature — isolatedEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, food taste testing, and interview, the facility failed to prepare pureed foods in a way to maintain nutritious value and palatability. This affected three residents (#30, #35, and #42) of three residents on pureed diets. The facility census was 45.Findings include:Observation of puree lunch preparation on 12/30/25 at 10:30 A.M. revealed Dietary [NAME] (DC) #266 to be preparing barbeque pork and mixed vegetables. While pureeing the mixed vegetables, DC #266 added about 3/4ths a cup of water and three unmeasured portions of thickener throughout the puree process. Post pureeing the mixed vegetables, this surveyor tasted them and noted the flavor to be bland with little to no flavor. The Dietary Manager tasted the mixed vegetables as well and confirmed them to have little to no flavor. Interview with the Dietary Manager on 12/30/25 at 10:35 A.M. confirmed DC #266 used water and unmeasured amounts of thickener to prepare the pureed mixed vegetables. Dietary Manager confirmed DC #266 should have used broth to maintain nutritious value and palatability of the pureed…
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 · D2025-12-31 · tag F0810 — isolatedProvide special eating equipment and utensils for residents who need them and appropriate assistance.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure residents were provided assistive devices as ordered. This affected one resident (#7) of one resident reviewed for assistive devices. The facility census was 45. Findings include:Record review revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, asthma, and depression. Review of an order dated 10/04/21 revealed Resident #7 was to receive plastic tumblers with lids for all drinks. Review of a minimum data set (MDS) dated [DATE] revealed Resident #7's cognition remained intact, she had no behaviors, and she received a mechanically altered diet. Review of a care plan initiated on 06/26/19 and revised on 12/26/25 revealed Resident #7 was at risk for altered nutrition and hydration related to body mass index, mechanically altered diet, and prone to edema. The goals were to consume adequate nourishment to achieve optimal nutrition with no signs or symptoms of dehydrations, aspirations…
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 19 citations
- Potential for harm · Ecited before2024-10-28 · 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
Based on medical record review, staff interview and review of the facility policy, the facility failed to complete comprehensive resident care plans. This affected four (Residents #9, # 15, #18, and #20) of 15 residents sampled. The facility census was 49 residents. Findings include: 1.Review of the medical record for Resident #18 revealed an admission date of 01/06/18 with diagnoses including hemiplegia and hemiparesis affecting right dominant side, major depressive disorder, dysphagia, aphasia, Parkinson's disease, and anxiety disorder. Review of the care plan for Resident #18 initiated 01/06/18 revealed it did not include a care plan for wandering, exit-seeking, or high risk for elopement. Review of the physician's orders for Resident #18 revealed an order dated 07/01/24 revealed for a Wanderguard to the right ankle for exit seeking. Review of the progress note for Resident #18 dated 07/01/24 revealed the resident had been attempting to exit seek out of the doors and a new order for a Wanderguard was received. Review of the progress notes for Resident #18 dated 08/31/24 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 · Ecited before2024-10-28 · 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 observation, medical record review, staff interview and review of the facility policy, the facility failed to properly clean and disinfect glucometers after use. This affected one (Resident #9) of 12 facility-identified diabetic residents (#1, #7, #8, #9, #17, #19, #22, #23, #25, #27, #38, #45) who resided on the front hallway. The facility also failed to ensure staff practice proper infection control practices to prevent the potential spread of infection during wound care. This affected one (Resident #23) of one resident observed for wound care. The facility census was 49 residents. Findings include: Review of the medical record for Resident #9 revealed an admission date of 03/05/24 with the diagnoses including chronic obstructive pulmonary disease, diabetes mellitus (DM), and Parkinson's disease. Review of the Minimum Data Set (MDS) assessment for Resident #9 dated 09/07/24 revealed the resident had no cognitive deficit, had DM as a current diagnoses and received daily insulin injections. Review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-28 · 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 and staff interview the facility failed to notify the physician of significant weight changes for a resident with congestive heart failure and failed to notify the physician of abnormal urinalysis results. This affected two (Residents #38 and #46) of 15 residents sampled. The facility census was 49 residents. Findings include: 1.Review of the medical record for Resident #38 revealed an admission date of 04/10/24 with diagnoses including acute respiratory failure with hypoxia, morbid obesity, and congestive heart failure. Review of the care plan for Resident #38 initiated 04/10/24 revealed the resident had a potential for fluid volume deficit related to diuretic use. Interventions included to monitor and document the resident's weight and report weight changes to the physician. Review of the weight record for Resident #38 revealed the resident weighed 289 pounds (lbs) on 04/10/24 and on 04/17/24 the resident weighed 294.8 lbs. Review of the weight record for Resident #38 revealed on 05/07/24 the resident weighed 304 lbs. and on 05/17/24 the resident…
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 · D2024-10-28 · 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
Based on medical record review, family interview, and staff interview, the facility failed to assist all dependent residents with oral hygiene. This affected one (Resident #22) of one residents reviewed for activities of daily living (ADL) care. The facility census was 49 residents. Findings include: Review of the medical record for Resident #22 revealed an admission date of 06/01/23 with diagnoses including dementia, major depressive disorder, type two diabetes, atherosclerotic heart disease, hypertension, and hypothyroidism. Review of the care plan for Resident #22 initiated 06/01/23 revealed the resident required the assistance of one staff with personal hygiene and oral care. Review of the Minimum Data Set (MDS) assessment for Resident #22 dated 08/16/24 revealed the resident had mild cognitive impairment and was to receive supervision/touching assistance with oral care. Review of the physician's orders for Resident #22 revealed an order dated 10/01/24 for denture care completed after each meal and at bedtime. The dentures were to be cleaned with a denture brush 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 · D2024-10-28 · 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 medical record review, staff interview, and observation, the facility failed to perform regular resident blood pressure checks and failed to apply thromboembolic deterrent (TED) hose as ordered. This affected two (Resident #38 and #29) of 15 residents sampled. The facility census was 49 residents. Findings include: 1. Review of the medical record for Resident #38 revealed an admission date of 04/10/24 with diagnoses including acute respiratory failure with hypoxia, hypertension, morbid obesity, and congestive heart failure. Review of the monthly physician's orders for Resident #38 revealed an order dated 06/12/24 for lisinopril (an anti-hypertensive medication) 2.5 milligrams (mg) once daily and an order dated 06/12/24 for spironolactone (a diuretic medication), and an order dated 10/06/24 to take full vital signs on a monthly basis, which included measuring blood pressure. Review of the vital sign records for Resident #38 dated 04/14/24 to 10/08/24 revealed monthly blood pressure checks were not completed in June, July, and August of 2024. There were no blood pressures…
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 · D2024-10-28 · 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
Based on medical record review, staff interview, and review of the facility policy, the facility failed to assess residents for elopement risk. Additionally, the facility failed to ensure residents were properly supervised to prevent falls. This affected two (Residents #15 and #20) of six residents reviewed for accidents. The facility census was 49 residents. Findings include: 1.Review of the medical record for Resident #15 revealed an admission date of 08/10/23 with diagnoses including dementia, expressive language disorder, major depressive disorder, gastro-esophageal disease, and chronic kidney disease. Review of the care plan for Resident #15 initiated 08/10/13 revealed it did not include the resident's risk for elopement or wandering behaviors. Review of the Minimum Data Set (MDS) assessment for Resident #15 dated 07/25/24 revealed the resident had impaired cognition and had no wandering behaviors during the review period. Review of the progress note for Resident #15 dated 10/08/24 revealed the resident had increased confusion and was standing by exit doors. Staff redirected…
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 · D2024-10-28 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, observation, staff interview and manufacturer's instructions, the facility failed to ensure staff primed insulin needles prior to insulin administration. This affected one (Resident #9) of five residents observed for medication administration. The facility census was 49 residents. Findings Include: Review of the medical record for Resident #9 revealed an admission date of 03/05/24 with the diagnoses including chronic obstructive pulmonary disease, diabetes mellitus (DM), and Parkinson's disease. Review of the Minimum Data Set (MDS) assessment for Resident #9 dated 09/07/24 revealed the resident had no cognitive deficit, had DM as a current diagnoses and received daily insulin injections. Review of the physician's orders for Resident #9 revealed an order dated 03/12/24 for the resident to receive Lantus insulin 20 units daily for DM via subcutaneous injection. Observation on 10/22/24 at 8:20 A.M. of insulin administration for Resident #9 per Registered Nurse (RN) #1 revealed the nurse dialed the pen to 20 units, cleansed the resident's abdomen, 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 · Fcited before2022-10-31 · tag F0880 — failed to prevent and control infections — widespreadProvide 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, facility policy review and interview the facility failed to implement an effective infection control program and policies and procedures to prevent the spread of infection including COVID-19 in the facility. This had the potential to affect all 40 residents residing in the facility. Findings include: 1. On 10/17/22 the facility identified 12 residents, Resident #5, #6, #7, #8, #9, #11, #15, #18, #19, #29, #31, #32 who currently had COVID-19 and were in isolation and two residents, Resident #12 and #14 who were symptomatic (of COVID-19) and in quarantine but had tested negative. The resident's rooms were located near or next to the rooms of residents who were not currently positive for COVID-19. On 10/17/22 between 11:26 A.M. and 11:32 A.M. observations revealed Resident #18 and #32's room doors were halfway open with no curtains pulled. Resident #8's room door was open all the way with a curtain pulled across the doorway that had about a three foot gap. Resident #14's room door was open all the way with a curtain pulled across the doorway. On 10/17/22 at 11:38…
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 · F2022-10-31 · tag F0882 — widespreadDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, facility policy review and interview the facility failed to ensure the designated Infection Preventionist, Registered Nurse #504 worked at least part-time and was involved in the Quality Assessment and Assurance Program to report on the facility Infection Control and Prevention Program. This had the potential to affect all 40 residents residing in the facility. Findings include: Review of the Quality Assurance and Performance Improvement (QAPI) Committee documentation revealed the facility identified Infection Preventionist, Registered Nurse #504 was not a member of the committee. Interview on 10/17/22 at 10:01 A.M. with the Administrator and Business Office Manager (BOM) #555 revealed the facility was currently in a COVID-19 outbreak. The facility had 13 residents and one staff who had confirmed positive tests for COVID-19. The facility had an additional two residents who had tested negative for COVID-19 but were displaying signs and symptoms of the virus. On 10/25/22 at 12:37 P.M. telephone interview with Infection Preventionist(IP)/Registered Nurse (RN)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-31 · 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, staff interview, and policy review, the facility failed to ensure Resident #7's advance directive decision was accurately documented for staff providing care. This affected one resident (#7) of 16 residents reviewed for advance directives. Findings include: Review of the medical record for Resident #7 revealed an admission date of 02/23/22. A physician's order on 03/08/22 related to advance directives indicated to discontinue full code status and change status to Do Not Resuscitate Comfort Care-Arrest (DNRCC-Arrest). The physician had also, on 03/02/22, signed a DNRCC-Arrest form which was located in the resident's record. The form stated Do Not Resuscitate Comfort Care protocol would be implemented in the event of a cardiac arrest or a respiratory arrest. However, review of the facility report sheet (a list of all residents used by nurses to give report of resident status to the oncoming shift that included code status) revealed Resident #7 was listed as being a full code (resuscitative measures to be implemented in the event of cardiac or respiratory…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-10-31 · 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 observation, record review, interview and facility policy review the facility failed to ensure timely notification to the physician and resident representative related to the development of new pressure ulcer areas and/or significant weight loss. This affected two residents (#22 and #28) of two residents reviewed for notification. Findings include: 1. Review of the medical record for Resident #22 revealed an original admission date on 06/26/17 and a readmission date of 04/13/19. Resident #22 had diagnoses including Parkinson's disease, atrial fibrillation, chronic obstructive pulmonary disease (COPD), dehydration, abnormal weight loss, anorexia nervosa-restricting type, major depressive disorder, and cerebral infarction (stroke). Review of the care plan, dated 07/08/17 revealed Resident #22 had actual and potential for impaired skin integrity. Interventions included report any red or open areas as indicated. The resident also had a plan related to risk for altered nutrition and hydration. Interventions included notify the registered dietitian (RD) and physician (MD) of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-10-31 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, facility policy review and interview the facility failed to provide an Advanced Beneficiary Notice (ABN) as required to Resident #12 and Resident #28 who were cut from Medicare Part A therapy services and remained in the facility. This affected two residents (#12 and #28) of three residents reviewed for beneficiary notices. Findings include: 1. Review of the medical record for Resident #12 revealed an admission date of 04/01/22 with medical diagnoses including unspecified dementia, generalized anxiety disorder, paranoid schizophrenia, adjustment disorder with depressed mood, chronic myeloproliferative disease, and delirium due to a known physiological condition. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 04/01/22 revealed Resident #12 had intact cognition with a Brief Interview of Mental Status (BIMS) score of 13 out of 15. The assessment revealed Resident #12 required limited to extensive assistance from one staff to complete activities of daily living (ADLs). Review of the beneficiary notices for Resident #12 revealed the resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-31 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure the State Long Term Care Ombudsman office was notified of facility initiated emergency transfers. This affected two residents (#44 and #45) of two residents reviewed requiring emergency transfers in the past three months. Findings include: Review of the medical record for Resident #44 revealed an admission date of 09/08/22. Record review revealed the resident was transferred to the hospital on [DATE]. Review of the medical record for Resident #45 revealed an admission date of 01/24/18. Record review revealed the resident was transferred to the hospital on [DATE]. Record review revealed no evidence the State Long Term Care Ombudsman office had been notified of the facility initiated emergent transfers to the hospital as required (at least 30 days had passed since the transfers occurred). Interview with Social Service (SS) #572 on 10/25/22 at 11:18 A.M. revealed the State Long Term Care Ombudsman office had not been notified of any facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-31 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and staff interview the facility failed to complete a comprehensive (Minimum Data Set (MDS) 3.0) assessment within 14 days after admission. This affected one resident (#30) of 14 residents reviewed for comprehensive MDS 3.0 assessments. Findings include: Review of the medical record for Resident #30 revealed an admission date of 09/27/22. The resident had diagnoses including end stage renal disease with hemodialysis, chronic pain, and rheumatoid arthritis. The resident had a physician's order for hemodialysis three times weekly and was on a renal diet. Record review revealed there was no evidence a comprehensive Minimum Data Set (MDS) 3.0 assessment had been completed for Resident #30 since admission. Interview with the Administrator on 10/25/22 at 9:25 A.M. confirmed the MDS 3.0 assessment had not been completed for the resident. The Administrator revealed the Director of Nursing, Assistant Director of Nursing, and the MDS nurse had all quit working at the facility around mid September 2022.
- Potential for harm · Dcited before2022-10-31 · 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
Based on record review, facility policy review and interview the facility failed to ensure comprehensive care plans were developed and initiated for each resident. This affected three residents (#30, #39 and #43) of 14 residents reviewed for comprehensive care plans. Findings include: 1. Review of the medical record for Resident #30 revealed an admission date of 09/27/22. The resident had diagnoses including end stage renal disease with hemodialysis, chronic pain, and rheumatoid arthritis. The resident had a physician's order for hemodialysis three times weekly and was on a renal diet. Record review revealed no evidence a comprehensive plan of care had been developed and initiated for Resident #30 since admission. Interview with the Administrator on 10/25/22 at 9:25 A.M. confirmed a comprehensive care plan had not been developed/completed for the resident. The Administrator revealed the Director of Nursing, Assistant Director of Nursing, and the Assessment (MDS) nurse had all quit working at the facility around mid September 2022. 2. Review of the medical record for Resident #43…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-10-31 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, facility policy review and interview the facility failed to ensure comprehensive care plans were revised following a change in condition for Resident #28 and Resident #32. This affected two residents (#28 and #32) of 14 residents reviewed for comprehensive care plans. Findings Include: 1. Review of the medical record for Resident #32 revealed an admission date on 08/13/21 with diagnoses including Alzheimer's Disease, unspecified displaced fracture of first cervical vertebra, pain, and other abnormalities of gait and mobility. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 08/22/22 revealed Resident #32 had impaired cognition with a Brief Interview for Mental Status (BIMS) score of three out of 15. The assessment revealed Resident #32 required staff supervision with set up assistance only to complete activities of daily living (ADLs). Review of progress note, dated 10/01/22 at 3:20 A.M. revealed a nurse sitting at the nurse's station heard a loud thud. Resident #32 attempted to go to the bathroom, fell, and hit her head.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-10-31 · 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
Based on observation, record review, facility policy review and interview the facility failed to monitor pressure ulcers for healing, complications, or changes in the wound characteristics. This affected two residents (#22 and #28) of three residents reviewed for pressure ulcers. Findings include: 1. Review of the medical record for Resident #22 revealed an original admission date of 06/26/17 and a readmission date of 04/13/19. Resident #22 had diagnoses including Parkinson's Disease, atrial fibrillation, chronic obstructive pulmonary disease (COPD), dehydration, abnormal weight loss, anorexia nervosa-restricting type, major depressive disorder, and cerebral infarction (stroke). Review of the care plan, dated 07/08/17 revealed Resident #22 had actual and potential for impaired skin integrity. Interventions included skin checks weekly and as needed. Review of the quarterly MDS 3.0 assessment, dated 07/28/22 revealed Resident #22 had impaired cognition with a Brief Interview for Mental Status (BIMS) score of three out of 15. The assessment revealed Resident #22 required total…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-31 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, staff interview, and facility policy review, the facility failed to implement nutritional recommendations to prevent or monitor for weight loss for Resident #22 and Resident #28. This affected two residents (#22 and #28) of three residents reviewed for nutrition. Findings include: 1. Review of the medical record for Resident #22 revealed an original admission date on 06/26/17 and a readmission date of 04/13/19. Resident #22 had diagnoses including Parkinson's disease, atrial fibrillation, chronic obstructive pulmonary disease (COPD), dehydration, abnormal weight loss, anorexia nervosa-restricting type, major depressive disorder, and cerebral infarction (stroke). Review of the plan of care, dated 07/08/17 revealed Resident #22 was at risk for altered nutrition. Interventions included administer medications as ordered and observe for effectiveness, continue to observe weights, labs, oral intakes, and other nutritional parameters with each nutritional review as indicated. Review of resident's weights dated from 07/01/22 to 10/2022 revealed Resident #22 weighed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-31 · 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
Based on record review, review of infection line listing reports, facility policy review and interview the facility failed to ensure antibiotic use protocols were followed to ensure the appropriate use of antibiotics. This affected two residents (#1 and #16) of two residents reviewed for urinary tract infections/antibiotic use. Findings include: 1. Review of the facility infection line listing report for August 2022 revealed one resident, Resident #1 was identified to have urinary tract infection. The listing report noted the resident was treated with antibiotics. However, the facility had no documentation the antibiotic use had been reviewed and met the criteria for appropriate antibiotic use (urine culture with >100,000 bacteria and symptomatic). Review of the medical record for Resident #1 revealed an admission date of 06/27/22. On 08/11/22 at 10:15 A.M. a nurse's note revealed the physician was in. The resident had increased confusion, dysuria, and foul smelling urine. New orders were obtained for a urinalysis and culture and sensitivity of the urine. Urine culture results 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.
“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. 1 Medicare payment denial on record.
- Medicare payment denial — starting 2024-11-20 for 16 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| CARECORE AT MAIN STREET | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 03/31/2025 |
| HERTANU, CHAIM | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 05/31/2023 |
| CARECORE HEALTH LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/31/2025 |
| MAIN STREET NURSING PROPCO, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/01/2024 |
| LLOYD, JOHN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2024 |
| WENTZ, TRACY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2023 |
CMS files one row per role, so the 12 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.
3 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.
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 366016. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-31, 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.