Cedarview Care Center
115 Oregonia Road, Lebanon, OH 45036 · For profit - Limited Liability company · 83 certified beds · (513) 932-1121 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 4.5% | 5.3% | 15.4% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 5.7% | 6.2% | 5.4% | typical |
| 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 | 1.3% | 0.4% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 69.0% | 30.1% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 1.6% | 0.1% | 0.1% | worse |
| Long-stay residents with falls causing major injury | 2.5% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 5.2% | 6.1% | 16.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 39.8% | 25.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.8% | 3.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 22.7% | 21.4% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 7.7% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 3.8% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 88.1% | 75.6% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 24.8% | 24.9% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 12.1% | 12.9% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 2.43 | 1.73 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.80 | 1.80 | 1.80 | 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.
40.1% 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 30 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 74.3% 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 35 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 0.24 therapist hours per resident per day in 2026Q1 — more than 33% 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
| 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 | 40.1%CMS range 26.3–57.5 | 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 | 11.1%CMS range 7.1–15.2 | 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 | 74.3% | 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 | 57.1% | 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 | 68.6% | 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 | 98.5% | 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 | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS 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 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.27 | 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 83 beds and averages 70.6 residents a day — about 85% occupied, or roughly 12 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.32 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.89 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.32 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 3.45 hrs/resident/day on weekends vs 4.68 on weekdays — 26% thinner on weekends — a notable drop. RN hours go from 0.96 to 0.70 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 54% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
29 citations, most serious first. The 10 most serious are shown; the remaining 19 are one tap away and print in full.
- Potential for harm · D2026-03-19 · 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
THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of the medication error log, review of the incident report, staff and resident interview, and policy review, the facility failed to ensure residents were free from significant medication errors. This affected one (Resident #25) out of 22 sampled residents. The facility census was 70. Findings Include: Review of the medical record for Resident #25 revealed an admission date of 10/03/25 with diagnosis including chronic obstructive pulmonary disease, type two diabetes, and chronic pain.Review of the Minimum Data Set (MDS) assessment for Resident #25 dated 01/22/26 revealed the resident had moderate intact cognition. Resident was also assessed to be dependent on staff for activities of daily living (ADLs).Review of the physician's orders for Resident #25 revealed an order dated 11/15/25 to 11/17/25 for oxycodone oral tablet 5 milligrams (mg) one tablet every six hours. Resident #25 had another order dated on 11/18/25 to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-19 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled 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, observation, staff interview, review of the facility document Stability of Common Insulins in Vials and Pens, and policy review, the facility failed to ensure the safe storage of insulin. This affected two (Resident #07 and #19 ) out of 17 residents with insulin orders. In addition, the facility failed to ensure ophthalmic medication was labeled with an open date. This affected one (Resident #39) out of 12 residents with ophthalmic orders. The facility census was 70.Findings Include:1. Review of the medical record for Resident #07 revealed an admission date of 01/20/26. Diagnoses included bipolar disorder, diabetes mellitus, and schizophrenia.Review of the minimum data set (MDS) assessment dated [DATE] revealed Resident #07 had severe cognitive impairment and was dependent on staff for activities of daily living (ADL).Review of Resident #07's physician orders revealed an order dated 02/17/26 for Insulin Lispro subcutaneous solution pen-injector 100 unit per milliliter (unit/mL)…
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 · D2024-08-13 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and facility policy review, the facility failed to administered medications to residents as ordered. The medication administration observation identified four medication errors out of 39 medications administered for a medication error rate of 10.26 percent. This affected three (#19, #26, and #27) of four residents reviewed for medication administration. The facility census was 70. Findings include: 1. Review of medical records for Resident #19 revealed an admission dated 02/04/23. Diagnoses included multiple sclerosis, peripheral vascular disease, age related cataract bilateral, dry eye syndrome of bilateral lacrimal glands, and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 was assessed as moderately cognitively impaired. Review of a physician order dated 07/25/24 revealed Resident #19 was ordered Refresh Liquigel Ophthalmic Gel one (1) percent (%) eye drops to instill one drop in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-15 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure dependent residents were assisted with repositioning to prevent skin impairment. This affected three (#46, #53, #72) of three residents reviewed for repositioning. The census was 74. Findings included 1. Review of Resident #46's medical record revealed an admission date of 12/29/23. Diagnoses included acute and chronic respiratory failure with hypoxia, obstructive uropathy, diabetes, cerebrovascular attack, tracheostomy, gastrostomy, and ventilator dependent. Review of the care plan for Resident #46 dated 01/02/24 revealed the resident was at risk for skin impairment related to immobility. Interventions included to assist to turn and reposition at frequent intervals to provide pressure relief and to offload the hips and sacrum to promote skin integrity. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 was rarely or never understood. The resident's was assessed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-15 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
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, the facility failed to complete an accurate skin assessment. This affected one (#72) of three residents reviewed for skin assessments. The census was 74. Findings included: Medical record review for Resident #72 revealed an admission date of 03/08/24. Diagnoses included respiratory failure with hypoxia or hypercapnia, obstructive uropathy, pneumonia, diabetes, and seizure disorder. Review of the admission Minimum Data Set (MDS) assessment for Resident #72 revealed the resident was rarely/never understood. The resident was dependent on toileting and bed mobility, was assessed with an indwelling catheter, was always incontinent for bowel, and was dependent on a tracheostomy and a ventilator. Review of a skin assessment dated [DATE] at 11:40 A.M. for Resident #72 documented by Licensed Practical Nurse (LPN) #77 revealed there was not documentation in the skin assessment grid for any new areas of skin impairment. Review of Resident #72's physician orders…
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 before2024-04-18 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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, staff interview, and policy review, the facility failed to ensure foods were stored in a manner to protect against the potential spread of food-borne illness. This had the potential to affect all 59 residents who received food from the kitchen. The facility identified 13 residents who were NPO (nothing by mouth) and did not receive food from the kitchen. The facility census was 72. Findings include: Observation on 04/18/24 at 1:16 P.M., revealed the refrigerator on the facility's C-hall contained 10 unlabeled containers, each containing unidentified substances. None of the containers were labeled nor dated. Additionally, there was a sandwich, which was loosely wrapped in a plastic sandwich bag, unsealed, unlabeled, and undated. Further observation revealed the refrigerator did not contain a thermometer, nor was any type of temperature log. Interview at the same time of the observation, with Registered Nurse (RN) #375 verified the 10 containers were unlabeled and undated and all foods in the refrigerator should be labeled and dated. RN #375 stated she thought…
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 · D2024-04-18 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to ensure the physician was notified of a change in condition. This affected one (#22) of five residents reviewed for nutrition. The facility census was 72. Findings include: Review of the medical record of Resident #22 revealed an admission date of 01/19/24. The resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. Diagnoses included end-stage renal disease, chronic diastolic heart failure, fluid overload, pulmonary embolism, chronic obstructive pulmonary disease, chronic respiratory failure, and obstructive sleep apnea. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition. The resident required setup assistance with eating, partial/moderate assistance with personal hygiene, sitting to lying, and rolling from side to side in bed, substantial/maximal assistance for lying to sitting on side of bed, and was dependent…
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 · D2024-04-18 · 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 — 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 Resident Assessment Instrument (RAI) User Manual, review of the facility's Minimum Data Set (MDS) Completion and Submission Timeframe's policy and procedure, and staff interview, the facility failed to ensure MDS discharge assessment was completed within 14 days of discharge. This affected one (#60) of one resident reviewed for MDS discharge assessments. The facility census was 72. Findings include: Review of the medical record for Resident #60 revealed an admission date of 08/09/23, with diagnoses of schizoaffective disorder, anxiety disorder, polysubstance abuse, and nicotine addiction. Resident #60 was discharged on 12/15/23. Review of the MDS assessment dated [DATE] revealed Resident #60 is cognitively intact. The resident is independent for ambulation, transfers, dressing, and toileting, requires set up assistance for eating, oral and personal hygiene, and supervision with bathing. Review of the MDS discharge assessment for Resident #60 revealed a completion…
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 before2024-04-18 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of the Resident Assessment Instrument (RAI) User Manual, review of the facility's Minimum Data Set (MDS) Completion and Submission Timeframe's policy and procedure, and staff interviews, the facility failed to ensure MDS assessments were transmitted within 14 days of completion date. This affected three (#25, # 50, and #59) of three residents reviewed for MDS assessment submissions. The facility census was 72. Findings include: 1. Review of the medical record for Resident #25 revealed an admission date of 12/16/14, with diagnoses of Alzheimer's disease, bi-polar disorder, schizoaffective disorder, anxiety disorder, and alcohol abuse. Review of the MDS assessment dated [DATE] revealed Resident #25 is cognitively intact. Resident #25 is independent for mobility with no devices, transfers, toileting, dressing, requires set up assistance for eating and oral hygiene, and supervision for showering and personal hygiene. Review of MDS assessments for Resident #25 revealed a MDS…
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 · D2024-04-18 · tag F0646 — isolatedNotify the appropriate authorities when residents with MD or ID services has a significant change in condition.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interviews, the facility failed to notify the state mental health authority of a significant change in condition for residents with mental disorders. This affected two (#9 and #49) of five residents reviewed for Pre-admission Screening and Resident Review, (PASARR) admission process. The total facility census was 72. Findings include: 1. Review of Resident #49's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #49 include dementia, encephalopathy, major depressive disorder and anxiety disorder. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had severely impaired cognition and was dependent on staff for self-care and mobility. Review of Resident #49's physician orders revealed the resident had orders for hospice service beginning on 07/27/23. Record review of Resident #49 revealed no Pre-admission Screening and Resident Review, (PASARR) within 14 days of a significant…
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 · D2024-04-18 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, medical record review,and policy review, the facility failed to ensure the plan of care reflected the fluid restriction as ordered by the physician. The affected one (#61) of one resident reviewed for fluid restriction. The total facility census was 72. Findings include: Review of Resident #61's medical record revealed the resident was admitted to the facility on [DATE] . Diagnoses for Resident #61 include acute respiratory failure with hypoxia, dementia, chronic gastric ulcer, malnutrition, dependence on oxygen, and heart failure. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE], revealed the resident had impaired cognition and required moderate assistance with mobility and supervision assistance with feeding self. Review of physician orders dated 01/30/24 revealed orders for No Added Salt diet, nutritional supplement two times a day. Orders also included a fluid restriction 2000 cubic centimeters (cc) per day and document every shift. 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 · D2024-04-18 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record review, resident interview, and staff interview, the facility failed to ensure physician orders were followed for assistive devices to prevent further contracture. This affected one (#52) of two residents reviewed for limited range of motion. The facility census was 72. Findings include: Review of the medical record of Resident #52 revealed an admission date of 02/07/22. The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]. Diagnoses included encephalopathy, anxiety, hypothyroidism, depression, chronic obstructive pulmonary disease, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had moderately impaired cognition. The resident was assessed as having impaired range of motion to all extremities. The resident was dependent on staff for all activities of daily living. Observation and interview on 04/15/24 at 10:05 A.M., revealed both of Resident #52's hands were contracted.…
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 · D2024-04-18 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, review of the Resident Assessment Instrument (RAI), and policy review, the facility failed to ensure a resident's significant weight loss was addressed in an accurate and timely manner. This affected one (#42) of three residents reviewed for weight loss. The facility also failed to ensure weights were completed per the physician's order. This affected two (#09 and #22) of five residents reviewed for nutrition. The facility census was 72. Findings include: 1. Review of the medical record of Resident #42 revealed an admission date of 04/10/23. Diagnoses included huntington's disease, mood disorder due to known physiological condition with depressive features, schizophrenia, and schizoaffective disorders. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had intact cognition. The resident exhibited delusions during the assessment period. Review of the medical record revealed, on 10/08/23, Resident #42 weighed 160.2…
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 · D2024-04-18 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, the facility failed to ensure the oxygen tubing was changed and dated as ordered by the physician. This affected for two (#19 and #61) of two residents reviewed for oxygen administration orders. The total facility census was 72. Findings include: 1. Review of Resident #19's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #19 include dementia, Down syndrome, chronic respiratory failure, and pseudobulbar affect. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE], revealed the resident had severely impaired cognition and required supervision of self-care and maximal assistance for mobility. Review of physician orders revealed Resident #19 was to receive oxygen two to four liters to keep oxygen saturation above 88 percent and oxygen tubing changed, label and date every Wednesday. Observation on 04/15/24 at 8:30 A.M., revealed Resident #19 oxygen tubing was not dated. Interview 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.
- Potential for harm · Dcited before2024-04-18 · tag F0914 — isolatedProvide bedrooms that don't allow residents to see each other when privacy is 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 and staff interview, the facility failed to provide full visual privacy for resident. This affected for two (#48 and #61) of three residents reviewed for physical environment. The total facility census was 72. Findings include: 1. Review of Resident #48's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #48 include acute respiratory failure, schizoaffective disorder, bipolar disorder, anxiety disorder, and depressive disorder. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE], revealed the resident had intact cognition and was dependent on staff for self-care and mobility. Observation on 04/15/24 at 8:32 A.M., revealed Resident #48 had no privacy curtain which prohibited full privacy around the entire bed. Resident #48 had a roommate. Interview on 04/15/24 at 8:32 A.M., with Licensed Practical Nurse (LPN) #356 and State Tested Nurse Assistant(STNA) #330 verified Resident #48 had no privacy curtain and full privacy…
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 · E2023-12-01 · tag F0694 — patternProvide for the safe, appropriate administration of IV fluids 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 staff interview, medical record review, and review of pharmacy board website, the facility failed to administer parenteral fluids per professional standards when they allowed a company who was not licensed in Ohio by the State Pharmacy Board to administer dangerous intravenous (IV) fluid medications to residents. This affected three (Resident #46, #48 and #65) of three reviewed for pharmacy services. The facility identified 13 former residents, (Residents #70,#71,#72,#73,#74,#75,#76,#77,#78,#79,#80,#81 and #82) and 32 residents who currently reside in the facility, (Residents #65,#2,#3,#5,#7,#10,#11,#48,#12,#15,#17,#18,#19,#21,#23,#26,#46, #28,#30,#31,#33,#38,#41,#42,#45,#51,#55,#57,#60,#62,#63,and #64) who received intravenous fluids through the unlicensed company. The facility census was 65. Findings include: 1. Record review of Resident #46 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #46 include pressure ulcer, diabetes, and surgical amputation. Review of 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 · E2023-12-01 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, medical record review, and review of pharmacy board website, the facility failed to provide pharmaceuticals services that assure the accurate acquiring, receiving, and dispensing of drugs when they allowed a company who was not licensed in Ohio by the State Pharmacy Board to administer dangerous intravenous (IV) fluid medications. This affected three (Resident #46, #48 and #65) of three reviewed for pharmacy services. The facility identified 13 former residents, (Residents #70,#71,#72,#73,#74,#75,#76,#77,#78,#79,#80,#81 and #82) and 32 residents who currently reside in the facility, (Residents #65,#2,#3,#5,#7,#10,#11,#48,#12,#46,#15,#17,#18,#19,#21,#23,#26,#28,#30,#31,#33,#38,#41,#42,#45,#51,#55,#57,#60,#62,#63,and #64) who received intravenous fluids through the unlicensed company. The facility census was 65. Findings include: 1. Record review of Resident #46 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #46 include pressure ulcer, diabetes, 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 · E2023-12-01 · tag F0837 — patternEstablish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, medical record review, and pharmacy board website review, the facility failed to ensure an outside Intravenous (IV) company (IV Company #700) had a proper license to provide services to residents. This affected three (Resident #46, #48 and #65) of three reviewed for pharmacy services. The facility identified 13 former residents, (Residents #70,#71,#72,#73,#74,#75,#76,#77,#78,#79,#80,#81 and #82) and 32 residents who currently reside in the facility, (Residents #65,#2,#3,#5,#7,#10,#11,#48,#46, #12,#15,#17,#18,#19,#21,#23,#26,#28,#30,#31,#33,#38,#41,#42,#45,#51,#55,#57,#60,#62,#63,and #64) who received intravenous fluids through the unlicensed company. The facility census was 65. Findings include: 1. Record review of Resident #46 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #46 include pressure ulcer, diabetes, and surgical amputation. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had intact…
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 · E2023-06-28 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation, policy review, and staff interview, the facility failed to prepare puree foods as planned in the facility's spreadsheet and recipes. This had the potential to affect all nine residents (Residents #1, #7, #9, #20, #23, #26, #27, #56, and #59) receiving pureed food from the kitchen. The facility census was 72. Findings include: Review of the facility's lunch menu spreadsheet dated 06/27/23 revealed the puree meal consisted of cheesy ham and egg scramble with a number 10 scoop size (three-eights cup), wheat toast with a number 16 scoop size (one-fourth cup), cereal, juice, and milk. Review of the facility's recipe for Cheesy Ham and Egg Scramble revealed for puree consistency required four quarts of liquid eggs, two pounds of ham and two pounds of shredded cheese to be mixed together, cooked, and then pureed with milk, to obtain a puree consistency. Observation on 06/27/23 at 7:14 A.M. revealed Dietary [NAME] (DC) #92 preparing pureed eggs, ham and cheese in a blender for the breakfast meal. There was no recipe or spreadsheet visible on the counter.…
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 before2023-06-28 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 policy review, observations, and staff interview, the facility failed to store foods, discard expired foods and maintain food equipment in good repair. This had the potential to affect 63 residents who received food from the kitchen. The facility census was 72. Findings include: 1. Observations on 06/25/23 at 9:05 A.M. with Dietary [NAME] (DC) #93 revealed the following concerns: there was an uncovered ceiling light fixture above the three-compartment sink; The deep fryer had food and debris built up along the edges and the deep fryer was not covered when not in use; The reach in freezer, located in the main kitchen area, had the exterior finish removed in areas measuring one-fourth of an inch up to a half-inch over 90 percent of each exterior door. The exposed areas were rust colored and noted to have areas which were non cleanable and unable to be sufficiently sanitized; The reach in refrigerator, in the main kitchen area had a container labeled sour cream, with an open date of 05/22/23; and the milk refrigerator outside temperature read 48 degrees Fahrenheit and there…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-06-28 · tag F0914 — patternProvide bedrooms that don't allow residents to see each other when privacy is needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and staff interviews, the facility failed to provide a full visual privacy of each resident. This affected six (Residents #7, #40, #50, #65, #68, and #226) of 56 residents residing in double occupancy rooms. The facility census was 72. Findings include: 1. Observation on 06/25/23 at 12:42 P.M. of Resident #50 and Resident #7's room revealed there was one dividing curtain hanging from ceiling between the end of Resident #50's footboard and the head of the bed of Resident #7. The curtain was only able to cover three-fourth of Residents #7's bed. There was a track on the ceiling but was missing a curtain on Resident #50's side of room. Interview on 06/25/23 at 12:46 P.M. with Licensed Practical Nurse (LPN) #37 verified there was only one curtain in Resident #50 and #7's room as a divider between sides of the room. LPN #37 verified the current curtain was unable to fully provide privacy to either resident because of the width of the curtain was not wide enough to cover each resident's room area. 2. Observation on 06/25/23 from 3:20 P.M. through 3:45 P.M. revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-28 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, the facility failed to treat residents with respect and dignity when they posted care information on the door of a resident's room. This affected one (Resident #22) of two residents reviewed for respect and dignity. The facility census was 72. Findings include: Record review for Resident #22 revealed an admission date of 03/12/21. Diagnoses included multiple sclerosis, carrier of bacterial diseases, urinary tract infection, and acute kidney failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was cognitively intact and required total dependence from staff for personal hygiene. Resident #22 had a urostomy and was always incontinent of bladder and always continent of bowel. Observation on 06/26/23 at 9:52 A.M. revealed a sign on the outside of the door of Resident #22's room that stated Please drain nephrostomy tube q (every) two hours during rounds. Interview with the Director of Nursing (DON) on 06/28/23 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-28 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on resident and staff interviews, policy review, observations, and record review, the facility failed to provide reasonable accommodation of a call light that adapted to the needs of the resident. This affected one (Resident #50) of three residents reviewed for accommodation of needs. The facility census was 72. Findings include: Review of Resident #50's medical record revealed an admission date 07/28/2001. Diagnoses included acute respiratory failure with hypoxia, bipolar disorder, anxiety, chronic respiratory failure, emphysema, adult failure to thrive, Wilson's disease, and insomnia. Review of the Minimum Data Set (MDS) assessment, dated 04/01/23, revealed Resident #50 had intact cognition and had verbal behavioral symptoms directed towards others occurring four to six days a week. Resident #50 was dependent on staff for eating, toileting, and wheelchair mobility. Resident #50 required two-person assistance with bed mobility and transfers. Resident #50 had upper extremity impairment and lower extremity impairment on both sides of her upper and lower body. Review of the plan…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-28 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
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, resident and staff interview, review of the facility's Self-Reported Incidents (SRIs), and policy review, the facility failed to timely report an allegation of misappropriation of a resident's credit card to administration and the State Survey Agency. This affected one (Resident #49) of one resident reviewed for abuse and misappropriation. The facility census was 72. Findings include: Record review for Resident #49 revealed the resident was admitted to the facility on [DATE]. Diagnoses included depression, muscle weakness, and altered mental status. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition and required limited assistance with mobility. Review of the facility's SRI , dated 06/26/23 at 5:54 P.M., revealed the Administrator filed an SRI report regarding Resident #49's allegation of a missing credit card. Interview on 06/26/23 at 8:38 A.M. with Resident #49 stated he was missing his credit card…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-06-28 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interview and record review, the facility failed to ensure a resident who required assistance from staff with activities of daily received bathing as scheduled. This affected one (Resident #32) of three residents reviewed for activities of daily living. The facility identified all 72 residents required assistance from staff with bathing. The facility census was 72. Findings include: Record review revealed Resident #32 was admitted on [DATE] with pertinent diagnosis of: morbid obesity, major depressive disorder, acute kidney failure, and hypotension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 was cognitively intact and required physical assistance from one person for bathing. Resident #32 did not reject care. Review of the electronic documentation and paper shower record sheets records on 06/28/23 revealed Resident #32 received a shower/bed bath on 5/02/23 and did not receive another one until 05/19/23. Resident #32 went 16 days without…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-28 · 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 staff interview and record review, the facility failed to have ensure the resident's pressure ulcers were documented accurately upon re-admission to the facility. This affected one (#28) of four residents reviewed for pressure ulcers. The facility census was 72. Findings include: Review of Resident #28's medical record revealed Resident #28 was readmitted to the facility on [DATE]. Diagnoses included stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle) of left buttock, stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fate may be visible but bone, tendon or muscle is not exposed) of the left ankle, stage IV pressure ulcer to the sacral region, stage IV pressure ulcer to the left hip. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 was cognitively impaired. Review of the hospital documentation dated 05/24/23 revealed Resident #28 had five stage IV pressure ulcers on the left hip, left buttocks, sacrum, right buttocks,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-28 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, policy review, and staff interview, the facility failed to complete hand hygiene after removing gloves during a resident's wound treatment. This affected one (Resident #58) of three residents reviewed for infections. The facility census was 72. Findings include: Record review for Resident #58 revealed an admission date of 03/09/22. Diagnoses included diffuse traumatic brain injury, carrier of bacterial diseases, severe sepsis with shock, and a pressure ulcer. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #58 was cognitively intact. Review of a physician's order dated 05/15/23 revealed to cleanse the pressure injury to left lateral foot between the fourth and fifth toes with soap and water or wound wash. Pat dry. Apply alginate and cover with dry dressing (either roll ABD and roll gauze or gauze and tape) every day shift for pressure injury and as needed for if dressing becomes dislodged or soiled. Observation of Licensed Practical…
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.
- No harm found · C2024-04-18 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and staff interview, the facility failed to post nurse staffing information that included the total number worked daily of Registered Nurses, Licensed Practical Nurses, and State Tested Nurse Aides. This had the potential to affect all 72 residents in the building. The census was 72. Findings include: Observation on 04/17/24, revealed the Nursing Staffing posting did not include the number of Registered Nurses (RN), Licensed Practical Nurses (LPN), and State Tested Nurse Aides (STNA) that were working. Review of the daily staffing posting from 03/01/24 to 04/17/24 revealed all the nursing staff postings sheets were missing the number of Registered Nurses (RN), Licensed Practical Nurses (LPN), and State Tested Nurse Aides (STNA) that worked. Interview on 04/18/24 at 12:43 P.M., with the Administrator verified the staffing posting did not show the number of working RN, LPN, or STNA.
- No harm found · Bcited before2023-06-28 · tag F0640 — patternEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of the resident assessment instrument (RAI) manual, the facility failed to ensure the residents' completed Minimum Data Set (MDS) assessments were submitted to the Centers for Medicare and Medicaid Service's (CMS) system within 14 days after completion of the assessment. This affected four (#4, #40, #42, and #51) of 18 residents reviewed for MDS assessments. The facility census was 72. Findings include: 1. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE]. Diagnoses included neurogenic bladder, multiple sclerosis and depression. Review of Resident #4's quarterly MDS assessment revealed Resident #4's quarterly MDS assessment was completed on 05/25/23 and the MDS assessment should have been submitted to the CMS system on 06/06/23. The MDS assessment was submitted to the CMS system on 06/20/23. This was greater than 14 days after the MDS assessment completion date. Interview on 06/28/23 at 1:22 P.M. with MDS…
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 2024-05-10 for 6 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.
Part of a chain
This home belongs to CCH HEALTHCARE — 33 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 2.5 | +1.5 vs chain |
| Health inspection | 4 of 5 | 2.4 | +1.6 vs chain |
| Staffing | 2 of 5 | 2.5 | -0.5 vs chain |
| Quality measures | 4 of 5 | 3.9 | +0.1 vs chain |
The other 32 homes this chain runs (chain average 2.5★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| CAPITAL FINANCE LLC | Organization | 5% OR GREATER SECURITY INTEREST | since 01/14/2015 |
| JORDAN, JENNIFER | Individual | W-2 MANAGING EMPLOYEE | since 01/01/2015 |
| POLSKY, ELLIOTT | Individual | W-2 MANAGING EMPLOYEE | since 01/01/2015 |
| STERN, JACOB | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2013 |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 81% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $655K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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 365690. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-19, 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.