Embassy Of Logan
300 Arlington Avenue, Logan, OH 43138 · For profit - Limited Liability company · 135 certified beds · (740) 385-2155 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- it has 1 actual-harm citation
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (2/5)
- CMS ownership filings flag it as owned by a private-equity firm or REIT — a category that performs worse on staffing on average, though that average says nothing certain about this home, and CMS filings undercount these ties, so other homes here may have them unflagged (what the research actually shows →)
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) | 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 | 5.6% | 5.3% | 15.4% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 3.5% | 6.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.2% | 0.2% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.8% | 0.4% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 14.0% | 30.1% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.6% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 8.1% | 6.1% | 16.1% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 29.2% | 25.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 99.0% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.5% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 26.2% | 21.4% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 11.5% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.9% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 69.4% | 75.6% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 18.9% | 24.9% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 14.3% | 12.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 0.95 | 1.73 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.99 | 1.80 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
41.8% 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 46 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 63.9% 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 36 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 28% 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 | 41.8%CMS range 30.8–53.9 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.3%CMS range 7.5–15.3 | 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 | 63.9% | 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 | 77.8% | 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 | 61.1% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 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 | 6.2%CMS range 3.1–11.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.73 | 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 135 beds and averages 93.3 residents a day — about 69% occupied, or roughly 42 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.08 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.35 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.96 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.82 hrs/resident/day on weekends vs 3.19 on weekdays — 12% thinner on weekends. RN hours go from 0.39 to 0.25 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 47% 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.
23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.
- Actual harm · Gcited before2023-06-20 · 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 observation, record review and interview the facility failed to maintain the outside physical environment in a safe manner to prevent Resident #2 from sustaining a fall with injury. Actual harm occurred on 03/25/23 when Resident #2, who was independent with the use of a motorized (power) wheelchair sustained a fall in the parking lot, when his wheelchair fell into a pot hole resulting in a proximal humerus fracture to his right arm. The resident had increased pain to the area and was unable to use the motorized wheelchair for independent mobility for a period of time following the incident/injury. This affected one resident (#2) of five residents reviewed for accidents. The facility census was 98. Findings include: Review of the medical record for Resident #2 revealed an admission date of 06/08/22 with diagnoses including quadriplegia, peripheral vascular disease, neuralgia, neuritis, depression, chronic pain, wheelchair dependent and on 03/26/23 a diagnosis of fracture of upper end of right humerus. Review of a power wheelchair mobility indoor driving assessment 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 · F2026-03-19 · 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, staff interview, and facility policy and procedure, the facility failed to prepare and serve food under sanitary conditions. This had the potential to affect the 92 of 92 residents who receive trays from the kitchen. The census was 92. Findings include: On 03/17/2026 at 10:33 A.M. Observation of the kitchen revealed the confection oven with food splatter and food crumbs. A container under the steam table with food debris, the wall behind the plate warmer with dust and dirt build up. The wall behind the table with the toaster with dried food splatter. 03/18/2026 at 2:20 P.M. observation of the kitchen with Dietary Manager #109 revealed the hanging electrical outlet over the serving line had a built up of dust hanging on it, and on the air conditioning unit. The trash can be beside the confection oven and in the dish washing area with no lid on them. The stove with dried food debris and splatter on it. The shelf under the tray line with crumbs and food debris on it. This was verified at the time of the observation with Dietary Manager #109. Review of Sanitary…
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 before2026-03-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 interviews, observation, policy and audit reviews, the facility failed to ensure water temperatures did not exceed 120 degrees Fahrenheit (F) in the shower rooms on hallways 200 and 400. This had the potential to affect 42 residents (200 Hallway-Resident #51, Resident #27, Resident #64, Resident #39, Resident #15, Resident #33, Resident #89, Resident #41, Resident #45, Resident #85, Resident #34, Resident #79, Resident #08, Resident #54, Resident #01, Resident #40, Resident #23, Resident #36, Resident #12, and Resident #72. 400 Hallway-Resident #65, Resident #29, Resident #20, Resident #77, Resident #71, Resident #92, Resident #58, Resident #26, Resident #81, Resident #07, Resident #67, Resident #18, Resident # 74, Resident #93, Resident #101, Resident #75, Resident #48, Resident #80, Resident # 52, Resident #82, Resident #04, and Resident #69). The census was 92.Review of facilities audit conducted of water temperature log from January 2026-March 2026 revealed documented water temperatures were above 120 degrees F on 03/09/26, 03/02/26, 02/23/26, 02/19/26, 02/09/26,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-19 · 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 interview, record review and policy review the facility failed to show documented evidence of resident and family participation in the care planning process. This affected one resident (#50) of one sampled for care planning. The facility census was 92. Findings include:Review of Resident #50's medical record revealed an admission date of 09/26/24 and diagnoses including dementia with behaviors, morbid obesity, diabetes, cirrhosis of the liver, hypertension, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a brief interview for mental status score of two out of 15 indicating the resident was severely cogitatively impaired. Further review of the MDS revealed Resident #50 used a wheelchair for mobility, required set up for eating, and was dependent on facility staff for all other activities of daily living.Further review of Resident #50's medical record revealed an undated invitation to a care conference on 12/16/25 at 10:00 A.M. However, no evidence 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 · D2026-03-19 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, and record review, the facility failed to follow up on appropriate and timely completion regarding correct eyeglass prescription. This affected one resident (Resident #11) of two residents reviewed for activities of daily living. The census was 92.Review of the medical record for Resident #11 revealed an admission date of 04/30/25. Diagnoses include schizoaffective disorder and chronic obstructive pulmonary disease (COPD). Further review of the medical record revealed Resident #11's eyeglasses were obtained while at the facility and added to Resident #11's inventory sheet on 09/19/25. Glasses adjustment by 360 Care completed on 11/04/25.On 03/16/26 interview with Resident #11 revealed eyeglasses are not the correct prescription, and I have told someone about this. On 03/17/26 at 2:10 P.M. interview with Associate #216 revealed 360 Care was supposed to be out 03/11/26 to see resident. Associate #216 presented documentation from 360 Care on 03/11/26 and glasses were adjusted. Resident said that he can't see out of the bifocal very well was documented in the note.…
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 before2026-03-19 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and interview, the facility failed to ensure the physician ordered treatment was implemented. This affected one resident (#9) of three residents reviewed for skin conditions. The facility census was 92. Findings Include:Review of the resident's medical record for Resident #9 revealed an initial admission date of 02/17/21 with the latest readmission date of 08/03/21 with the diagnoses including but not limited to polyneuropathy, chronic obstructive pulmonary disease, diabetes mellitus, dysphagia, speech disturbances, anxiety disorder, schizophrenia, hyperlipidemia, dry eye syndrome, GERD, PTSD, major depressive disorder, BPH and insomnia. Review of the plan of care dated 11/28/25 revealed the resident had impaired skin integrity related to a skin tear to the left outer knee. Interventions included air mattress to promote skin integrity, check patency every shift, encourage resident to elevate feet while in chair, encourage to turn and reposition every two hours,…
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 before2026-03-19 · 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
Based on medical record review, interview and policy review the facility failed to follow physician recommended parameters for medication. This affected one resident (Resident #5) of five residents reviewed for unnecessary medication. The census was 92. Review of the medical record for Resident #5 revealed an admission date of 10/31/25 and diagnoses of cerebral infarction, unspecified and unspecified asthma, uncomplicated. Review of medical orders revealed an order from 01/30/26 for Metoprolol Tartrate Oral Tablet 25 milligrams (MG) oral tablet 25 MG (Metoprolol Tartate). Give 1.5 tablet by mouth two times a day for hypertension (HTN). Hold if static blood pressure (SBP) below 110 or heart rate (HR) below 60. Review of the medical administration record revealed no documented SBP or HR from 01/30/26-02/26/26. On 02/26/26 pharmacy recommended to give 1.5 tablet by mouth two times a day for hypertension (HTN). Hold if static blood pressure (SBP) below 110 or heart rate (HR) below 60. On 03/18/26 at 11:36 A.M. interview with Associate #114 confirmed medication should have been held 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 · D2026-03-19 · 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 and interview, the facility failed to maintain a complete and accurate medical record. This affected three residents (#5, #9 and #12) of 19 sampled residents. The facility census was 92. Findings Included:1. Review of the resident's medical record for Resident #9 revealed an initial admission date of 02/17/21 with the latest readmission date of 08/03/21 with the diagnoses including but not limited to polyneuropathy, chronic obstructive pulmonary disease, diabetes mellitus, dysphagia, speech disturbances, anxiety disorder, schizophrenia, hyperlipidemia, dry eye syndrome, GERD, PTSD, major depressive disorder, BPH and insomnia. Review of the plan of care dated 11/28/25 revealed the resident had impaired skin integrity related to a skin tear to the left outer knee. Interventions included air mattress to promote skin integrity, check patency every shift, encourage resident to elevate feet while in chair, encourage to turn and reposition every two hours, evaluate wound…
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 before2024-07-02 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and facility policy review, the facility failed to document treatments completed on two pressure ulcers for one resident (#111) of three residents reviewed. The facility census was 96. Findings include: Review of the medical record for Resident #111, revealed an admission date of 09/29/20. Diagnoses included but were not limited to schizophrenia, other reduced mobility pressure ulcer of left buttock stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) and dependence on other enabling machines and devices. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 out of 15 which indicated cognitive intactness. The resident was assessed to require dependence on toilet hygiene, partial/moderate assistance with transfers and independent with bed mobility. The resident was also…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-04-04 · tag F0580 — failed to tell family and doctor about changes — patternImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review ,staff interview, and facility policy review, the facility failed to ensure the physician was notified after a change in condition of a new wound or the worsening of a current wound. This affected four residents (#3, #74, #89, and #93) of seven reviewed for skin impairments. Facility census was 98. Findings include: 1. Review of the medical record for the Resident #89 revealed an admission date of 06/09/23. Diagnoses included depression, heart failure, diabetes, end stage renal disease, and absence of left leg below the knee. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #89 was cognitively intact and required supervision touching assistance for personal hygiene and activities of daily living. Review of the plan of care dated 01/2024 revealed Resident #89 was at risk for skin impairments with interventions to inspect for reddened areas during daily care, weekly skin assessments, charge nurse to notify wound nurse, physician and family of any new areas, 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 · E2024-04-04 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and staff interview, the facility failed to ensure residents' rooms were maintained in a safe, functional, and sanitary manner. This affected six residents (Resident #6, #21, #53, #62, #63, and #152) of 32 that were observed for room conditions. The facility census was 98. Findings include: 1. Review of Resident #6's room on 04/01/24 at 11:39 A.M. revealed the overbed light had a bulb that was burning out in the front of the overbed light. The light would turn on, but shined a pinkish-red color and was not fully lit. The resident's wall next to her bed had chipped paint and was in need of being painted. The entry door on the inside was noted to have chipped paint and was in need of being painted. On 04/04/24 at 8:23 A.M., a follow up observation was made of Resident #6's room and her room remained in disrepair. In addition to the above findings, the vent and surrounding ceiling area was noted to be covered in dust. Findings were verified by Maintenance Director #22. 2. Review of Resident #21's room on 04/01/24 at 10:02 A.M. revealed the floor tile next to her…
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 12 citations
- Potential for harm · Dcited before2024-04-04 · 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, staff interview, and policy review the facility failed to ensure all resident Pre-admission Screening and Resident Review (PASRR) documents were accurate to resident current conditions and diagnoses. This affected one (Resident #6) of one residents reviewed for PASRR documents. The facility census was 98. Findings Include: Review of Resident #6's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included unspecified dementia with agitation/ mood disturbance, anxiety disorder, major depressive disorder (MDD), and delusional disorder. Review of Resident #6's Preadmission Screening and Resident Review (PASRR) Identification Screen dated 11/30/23 revealed under Section (D.) the resident was identified as having a diagnosis of dementia. Under Section (E.) Indications of Serious Mental Illness, the resident was identified as having the diagnosis of a mood disorder and anxiety. Delusional disorder was not marked despite that being a diagnosis 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 · Dcited before2024-04-04 · 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, staff interview, and policy review, the facility failed to ensure all significant mental health changes were communicated to the state mental health agency. This affected one (Resident #6) of one residents reviewed for PASRR documents. The facility census was 98. Findings Include: Review of Resident #6's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included unspecified dementia with agitation/ mood disturbance, anxiety disorder, major depressive disorder (MDD), and delusional disorder. Review of Resident #6's Preadmission Screening and Resident Review (PASRR) Identification Screen dated 11/30/23 revealed under Section (D.) the resident was identified as having a diagnosis of dementia. Under Section (E.) Indications of Serious Mental Illness, the resident was identified as having the diagnosis of a mood disorder and anxiety. Delusional disorder was not marked despite that being a diagnosis the resident was known to have upon admission. 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 before2024-04-04 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and facility policy review, the facility failed to ensure skin and wound assessments were completed thoroughly, accurately, and timely for three residents (#3, #74 and #89) of four reviewed for non-pressure wounds. The facility census was 98. Findings include: 1. Review of the medical record for the Resident #89 revealed an admission date of 06/09/23. Diagnoses included depression, heart failure, diabetes, end stage renal disease, and absence of left leg below the knee. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #89 was cognitively intact and required supervision touching assistance for personal hygiene and activities of daily living Review of the plan of care dated 01/2024 revealed Resident #89 was at risk for skin impairments with interventions to inspect for reddened areas during daily care, weekly skin assessments, charge nurse to notify wound nurse, Physician and family of any new areas, and wound care practitioner to eval and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-04-04 · 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, skin assessment review, staff interview, and facility policy review, the facility failed to properly document a newly identified pressure wound. This affected one (Resident #93) of the seven residents reviewed for skin assessment accuracy. The facility census was 98. Findings include: Review of the medical record for Resident #93 revealed an admission date of 11/02/23. Diagnoses included delirium, vascular dementia, hemiplegia affecting the left non-dominant side, and a history of falling. Review of Resident #93's significant change 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. Resident #93 was noted to display disorganized thinking, inattention, rejection of care and delusions. Resident #92 was noted to to experience impairment to one upper and one lower extremity and required substantial to maximal assistance for bed mobility and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-04-04 · 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 record review and staff interview, the facility failed to ensure a resident receiving a narcotic pain medication ordered on an as needed basis (prn) had parameters ordered from the physician on when to administer the medication. This affected one (Resident #6) of five residents reviewed for unnecessary medications. The facility census was 98. Findings include: Review of Resident #6's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included unspecified dementia, opioid use, and a history of a displaced fracture of the upper end of the left humerus with routine healing. A review of Resident #6's physician's orders revealed she had an order to received Norco (Acetaminophen and Hydrocodone) 5-325 milligrams (mg) one half tablet by mouth (po) twice a day on a scheduled basis beginning on 02/21/24. Her orders also included the use of Norco 5-325 mg one half tablet po every six hours as needed for pain. There was no direction for the nurses to know when to administer the prn…
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 · D2024-04-04 · tag F0773 — isolatedProvide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
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 laboratory tests were completed as ordered by the physician. This affected one (Resident #62) of five residents reviewed for unnecessary medications. The facility census was 98. Findings include: Review of Resident #62's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included mood disorder, bipolar disorder, and major depressive disorder. Review of Resident #62's physician's orders revealed the resident had an order to receive Depakote (an anti-convulsant also used in the treatment of bipolar disorder) Delayed Release (DR) 500 milligrams by mouth (po) twice a day for mood disorder. The order had been in place since 10/29/20. Her physician's orders also included the need to obtain a Depakote level every six months and as needed. That order had been in place since 01/20/22. Further review of Resident #62's electronic medical record (EMR) revealed it was absent for evidence a Depakote level 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 · Dcited before2023-06-20 · 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 all resident Pre-admission Screening and Resident Review (PASRR) documents were accurate to resident current conditions and diagnoses. This affected two (Resident #59 and Resident #61) of four residents reviewed for PASRR documents. The census was 98. Findings Include: 1. Resident #59 was admitted to the facility on [DATE]. Her diagnoses were neurocognitive disorder with lewy bodies, chronic obstructive pulmonary disease, major depressive disorder, hyperlipidemia, occlusion and stenosis of unspecified carotid artery, psychotic disorder with delusions due to known physiological condition, other symbolic dysfunctions, insomnia, anxiety disorder, cognitive communication deficit, and mood disorder. Review of her Minimum Data Set (MDS) assessment, dated 04/19/23, revealed she had a mild cognitive impairment. Review of Resident #59 PASRR document, dated 08/24/20, revealed under Section C, the document indicated she did not have a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-06-20 · 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 interview, the facility failed to ensure all significant mental health changes were communicated to the state mental health agency. This affected two (Resident #59 and Resident #61) of three residents reviewed for PASRR documents. The census was 98. Findings Include: 1. Resident #59 was admitted to the facility on [DATE]. Her diagnoses were neurocognitive disorder with lewy bodies, chronic obstructive pulmonary disease, major depressive disorder, hyperlipidemia, occlusion and stenosis of unspecified carotid artery, psychotic disorder with delusions due to known physiological condition, other symbolic dysfunctions, insomnia, anxiety disorder, cognitive communication deficit, and mood disorder. Review of her Minimum Data Set (MDS) assessment, dated 04/19/23, revealed she had a mild cognitive impairment. Review of Resident #59 PASRR document, dated 08/24/20, revealed under Section C, the document indicated she did not have a diagnosis of dementia. Also, review of Section D,…
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 · D2023-06-20 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to implement a care plan related to non compliance/refusal of activities of daily living care for Resident #61. This affected one resident (Resident #61) of four residents reviewed for activities of daily living care. The facility census was 98. Findings include: Resident #61 was admitted to the facility on [DATE] with diagnoses including hemiplegia to right side related to cerebral infarction, non traumatic intracerebral hemorrhage, atrial fibrillation, congestive heart failure, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #61 was cognitively intact with no behaviors. Resident #61 required extensive assistance of two persons for bed mobility, transfers, dressing, toilet use, personal hygiene and total dependence of two persons for bathing. Review of the nursing progress notes dated 01/01/23 through 06/10/23 revealed random non compliance with care and treatment. Review of the plan of care…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-06-20 · 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 observation, interview and record review the facility failed to revise the plan of care of Resident #2 related to being up in his power wheelchair. This affected one ( Resident #2) of five residents reviewed for updated care plan. The facility census was 98. Findings include: Review of the medical record for Resident #2 revealed an admission date of 06/08/22 with diagnoses including quadriplegia, peripheral vascular disease, neuralgia, neuritis, depression, chronic pain, wheelchair dependent and on 03/26/23 a diagnosis of fracture of upper end of right humerus. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #2 was cognitively intact, and was total dependence on two persons for bed mobility, transfers, toileting and bathing. Resident #2 required supervision with locomotion. Review of the progress notes for Resident #2 revealed a Nurse Practioner (NP) note dated 05/10/23 revealed the orthopedic physician wrote an order on 05/09/23 for Resident #2 stating it was okay for 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 · D2023-06-20 · 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, interviews, record reviews, and review of facility policy, the facility failed to ensure residents received care and services to prevent worsening of contracture's. This affected two residents (#18 and #34) out of the four residents reviewed for limited range of motion during the annual survey. The facility census was 98. Findings include: 1. Record review for Resident #18 revealed this resident was admitted to the facility on [DATE] and had diagnoses including multiple sclerosis, need for assistance with personal care, muscle weakness, and reduced mobility. Review of the admission/5-day Minimum Data Set (MDS) assessment, dated 05/28/23, revealed this resident had mildly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 11 out of 15. This resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, and toileting and to require extensive assistance from one staff member for eating. This resident was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-20 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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 facility policy review, the facility failed to provide proper justification for the use of psychotropic medications. This affected two (Residents #21 and #64) of five residents reviewed for unnecessary medications. The census was 98. Findings Include: 1. Resident #21 was admitted to the facility on [DATE]. Her diagnoses were dementia, pneumonitis, delirium, muscle weakness, repeated falls, shortness of breath, anxiety disease, major depressive disorder, dysphagia, hyperlipidemia, hypertension, osteoarthritis, cognitive communication deficit, and traumatic subdural hemorrhage. Review of her Minimum Data Set (MDS) assessment, dated 04/02/23, revealed she had a significant cognitive impairment. Review of Resident #21 current physician orders revealed an order for Quetiapine 50 milligrams (mg) twice daily for paranoia and delusional disorder. Review of Resident #21 psychiatric notes, dated 11/09/22 and 01/10/23, revealed she was ordered Quetiapine for a mood…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to EMBASSY 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 | 3 of 5 | 2.4 | +0.6 vs chain |
| Health inspection | 3 of 5 | 2.1 | +0.9 vs chain |
| Staffing | 2 of 5 | 1.8 | +0.2 vs chain |
| Quality measures | 4 of 5 | 4.4 | -0.4 vs chain |
The other 32 homes this chain runs (chain average 2.4★, 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
CMS ownership filings flag an owner of this facility as a private-equity firm. That’s a fact worth knowing: peer-reviewed research links private-equity and REIT ownership to lower staffing and more citations on average — though any individual home can run well or poorly regardless. Read the inspection and staffing record above on its own merits.
- AH DYNASTY LLC — private equity · 50.00% share · Indirect Ownership Interest
- GSR DYNASTY LLC — private equity · 50.00% share · Indirect Ownership Interest
Source: CMS SNF ownership filings (PECOS). These flags are self-reported and undercount — federal auditors (GAO) and researchers find CMS captures only a fraction of true private-equity and REIT ties, so the absence of a flag on other homes is not proof they lack investor owners. How investor ownership affects care →
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| EMBASSY HEALTHCARE HOLDINGS INC | Organization | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/01/2020 |
| AARON HANDLER FAMILY DYNASTY TRUST | Organization | INDIRECT OWNERSHIP INTEREST | since 03/01/2020 |
| AH DYNASTY LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 03/01/2020 |
| GEORGE S. REPCHICK 2020 FAMILY DYNASTY TRUST | Organization | INDIRECT OWNERSHIP INTEREST | since 03/01/2020 |
| GSR DYNASTY LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 03/01/2020 |
| HERITAGE EMPLOYMENT SERVICES, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/13/2025 |
| HANDLER, AARON | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2020 |
| MILLER, DANIEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2024 |
| REPCHICK, GEORGE | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2020 |
| SAUPE, ERIC | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/01/2024 |
CMS files one row per role, so the 16 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
6 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.
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 $436K 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 365435. 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.