Otterbein Loveland
6405 Small House Circle, Loveland, OH 45140 · Non profit - Church related · 60 certified beds · (513) 833-0472 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- 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
- it has 1 actual-harm citation
- a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 3 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 | 3 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 3.2% | 5.3% | 15.4% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 7.7% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.3% | 0.2% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.4% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 8.1% | 30.1% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.1% | 3.2% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 4.2% | 6.1% | 16.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 30.0% | 25.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 92.2% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.4% | 3.4% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 32.5% | 21.4% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 9.9% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 91.7% | 75.6% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 25.8% | 24.9% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 19.9% | 12.9% | 12.0% | 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.
51.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 70 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 13.8% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 29 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.34 therapist hours per resident per day in 2026Q1 — more than 56% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 | 51.2%CMS range 43.0–61.1 | 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 | 11.2%CMS range 7.0–16.4 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 13.8% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 24.1% | 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 | 13.8% | 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 | 86.4% | 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 | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF 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 | 6.3%CMS range 2.7–12.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.95 | 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 60 beds and averages 60.7 residents a day — about 101% occupied, or roughly -1 beds typically open. It runs essentially full — expect a waiting list. 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.
Weekend coverage: total nurse staffing is 3.81 hrs/resident/day on weekends vs 4.14 on weekdays — 8% thinner on weekends. RN hours go from 0.66 to 0.37 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 53% 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 more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
27 citations, most serious first. The 11 most serious are shown; the remaining 16 are one tap away and print in full.
- Actual harm · Gcited before2023-05-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, staff interviews, and review of facility incident log, the facility failed to ensure residents received adequate supervision to prevent a fall with injury. Actual harm occurred when Resident #24 who was assessed and care planned for two staff assistance for toileting fell and sustained a fracture which required hospitalization and surgical intervention after being left unattended while toileting. This affected one resident (#24) out of the three residents reviewed for falls during the annual survey. The facility census was 57. Findings include: 1. Record review for Resident #24 revealed this resident was admitted to the facility on [DATE] and had diagnoses including difficulty walking, muscle weakness, shortness of breath, and restlessness and agitation. Review of the annual Minimum Data Set (MDS) assessment, dated 01/25/23, revealed this resident was assessed to have moderately impaired cognition. This resident was assessed to require extensive assistance from two staff members for bed…
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 before2026-03-26 · 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 review of the facility policy, the facility failed to ensure staff stored and prepared food in a sanitary manner, failed to ensure dishwasher temperatures reached safe levels, and failed to ensure hot food was held at safe and proper temperatures. This affected 21 (#22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #36, #37, #38, #39, #40, #41, #42, and #43) residents who received food prepared in the House Five kitchen of 56 residents residing in the facility. The facility census was 56 residents. Findings include: 1.Observation on 03/24/26 at 7:54 A.M. of the House Five kitchen refrigerator with Dietary Technician (DT) #506 revealed it contained an undated and uncovered pitcher of pink liquid and a piece of cardboard from a drink box was holding the water dispenser shut on the front of the refrigerator. Observation of the House Five kitchen freezer revealed it contained the following items: two undated medical ice packs, two undated gallon bags full of ice with ice crystals on them, an undated loaf of gluten free bread which…
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 · D2026-03-26 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
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 police report, staff interview, resident representative interview, and review of the facility policy manual, the facility failed to ensure the privacy of resident's health information. This affected one (Resident #71) of one resident reviewed for privacy of medical records. The facility census was 56 residents.Findings include:Review of the medical record for Resident #70 revealed an admission date of 09/10/25 with diagnoses including COVID-19, depression, and macular degeneration and a discharge date of 09/30/25. Review of the Minimum Data Set (MDS) assessment for Resident #70 dated 09/30/25 revealed the resident was cognitively intact and required supervision with activities of daily living (ADLs.) Review of nurse progress note for Resident #70 dated 10/01/25 revealed the resident left the facility against medical advice (AMA) on 09/30/25 per the request of the resident's representative. Upon discharge Licensed Practical Nurse (LPN) #142 accidentally provided 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 · D2026-03-26 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
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 police report, staff interview, resident representative interview, and review of the facility policy, the facility failed to provide a safe and orderly resident discharge from the facility. This affected one (Resident #70) of two residents reviewed for discharge. The facility census was 56 residents.Findings include:Review of the medical record for Resident #70 revealed andadmission date of 09/10/25 with diagnoses including COVID-19, depression, and macular degeneration and a discharge date of 09/30/2. Review of the Minimum Data Set (MDS) assessment for Resident #70 dated 09/30/25 revealed the resident was cognitively intact and required supervision with activities of daily living (ADLs.) Review of nurse progress note for Resident #70 dated 10/01/25 revealed the resident left the facility against medical advice (AMA) on 09/30/25 per the request of the resident's representative. Upon discharge Licensed Practical Nurse (LPN) #142 accidentally provided Resident #70's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-26 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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
Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure resident pain medication was available for administration. This affected one (Resident #100) of six residents reviewed for medication availability. The facility census was 56 residents.Findings include: Review of the medical record for Resident #100 revealed an admission date of 09/19/25 diagnoses including osteoporosis and wedge compression fracture of first lumbar vertebra with a discharge date of 09/20/25.Review of the discharge Minimum Data Set (MDS) assessment for Resident #100 dated 9/20/25 revealed the resident's cognition and activities of daily living (ADL) needs were not assessed.Review of the baseline care plan for Resident #100 dated 09/19/25 at 8:15 P.M. revealed the resident was alert and oriented to person, place, and situation, but had a short term memory problem. Resident #100 required supervision with bed mobility, transfers, and toileting and was independent with eating. Resident #100 had lower back pain related to a fall with a fracture and rated 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.
- Potential for harm · Dcited before2026-03-26 · 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
Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure staff donned proper personal protective equipment (PPE) for residents with physician's orders for enhanced barrier precautions (EBP). This affected one (Resident #31) of two residents with indwelling catheters. The facility census was 56 residents. Findings include: Review of the medical record for Resident #31 revealed an admission date of 01/29/24 with diagnoses including right hip fracture, dementia, insomnia, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment for Resident #31 dated 01/15/26 revealed the resident had severe cognitive impairment and was dependent on staff assistance with activities of daily living (ADLs.) Review of the care plan for Resident #31 dated 01/13/26 revealed the resident had an indwelling catheter related to skin breakdown and urinary retention. Interventions included staff to maintain EBP for the resident due to the presence of the indwelling catheter. Review of the physician's orders for Resident #31 dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-08-25 · 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, review of dishwasher, refrigerator, freezer, and food temperature logs, and policy review, the facility failed to ensure foods were stored in a manner to prevent spoilage and contamination and failed to ensure the kitchen and dishware were maintained in a sanitary manner. This had the potential to affect all 58 residents residing in the facility. The census was 58. Findings include: 1. During the initial kitchen tour on 08/18/25 from 8:48 A.M through 10:20 A.M. of each facility house with Dietary Technician (DT) #205 revealed, at 8:48 A.M., there was an open container of sour cream dated 08/04/25 with a used by date of 08/11/25 and an open unmarked package of food, identified by DT #205 to be fish aquarium food. Review of the food temperature log revealed no documentation of prepared food temperatures for all three meals for 15 days in July 2025. There were no refrigerator temperatures logged for August 2025 for refrigerator #2 and no temperatures logged for outside freezer #3 for July and August 2025.Interview with DT #205 verified 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 · F2025-08-25 · tag F0868 — widespreadHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview, review of Quality Assurance meeting sign-in sheets, and policy review, the facility failed to provide evidence the Medical Director attended and Quality Assurance committee meetings at least quarterly. This had the potential to affect all 58 residents. The census was 58.Findings Include:Review of the sign-in-sheets of the quarterly Quality Assurance (QA) committee meetings dated 09/30/24, 12/20/24, 03/28/25, and 06/19/25 revealed Medical Director #306 did not sign the sign-in attendance paperwork to show attendance.Interview on 08/25/25 at 1:58 P.M. the Administrator verified the MD must attend and participate at each quarterly QA committee meeting. The Administrator stated MD #306 did not sign the sign-in attendance sheet, and stated the MD #306 attended by telephone. The Administrator verified there was no other documentation to show MD #306 attended or participated in the most recent previous quarterly QA meetings. Review of facility policy titled, Quality Assurance and Performance Improvement Policy, dated 07/24/17, revealed the committee is made up 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 · E2025-08-25 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, review of water temperature logs, review of a repair quote, and policy review, the facility failed to ensure the residents environment was safe, comfortable, and homelike. This affected nine (#14, #17, #19, #23, #34, #52, #54, #56, and #59) of nice residents reviewed for environment. The census was 58. Findings include: 1. Observation of Resident #19's room on 08/18/25 at 4:10 P.M. revealed the carpet in the resident's room was heavily stained. Observation of Resident #43's bathroom on 08/19/25 at 9:39 A.M. revealed there were three lights above the sink area that were dim to the point they were out. Interview with Maintenance Supervisor (MS) #63 on 08/21/25 at 7:12 A.M. confirmed the carpet in Resident #19's room was heavily stained and stated the lights in Resident #43's bathroom contained light bulbs that would go dim before they were ready to burn out. MS #63 confirmed the bathroom's lighting was very dim. 2. Medical record review for Resident #17 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 · E2025-08-25 · tag F0679 — failed to provide activities — patternProvide activities to meet all resident's needs.
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, resident, resident representative, and staff interviews, review of activity calendars, and policy review, the facility failed to ensure activity programs were provided for residents to support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. This affected five (#16, #20, #36, #43, and #48) of five residents reviewed for activities. The census was 58.Findings include: 1. Medical record review for Resident #16 revealed an admission date of 01/26/22. Medical diagnoses included non-traumatic brain dysfunction, dementia, and diabetes. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was severely cognitively impaired. Review of the activity care plan dated 05/26/25 for Resident #16 revealed she enjoyed activity programs but needed encouragement, reminders, and motivation. Interventions included to invite her even if she may not attend or participate…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-08-25 · tag F0712 — patternEnsure that the resident and his/her doctor meet face-to-face at all required visits.
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 the Medical Director visited residents once every 60 days. This affected four (#4, #16, #43, and #61) of four reviewed for physician visits. The census was 58. Findings include: 1. Medical record review for Resident #4 revealed an admission date of 05/16/23. Medical diagnoses included pneumonia meningitis, ulcerative colitis, and viral hepatitis.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was cognitively intact.2. Medical record review for Resident #16 revealed an admission date of 01/26/22. Medical diagnoses included non-traumatic brain dysfunction, dementia and diabetes. Review of the quarterly MDS assessment dated [DATE] revealed Resident #6 was severely cognitively impaired. 3. Medical record review for Resident #43 revealed an admission date of 02/28/23. Medical diagnoses included non-traumatic brain dysfunction, dementia, cancer, and coronary artery disease.Review of quarterly…
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 16 citations
- Potential for harm · Ecited before2025-08-25 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and policy review. the facility failed to ensure soiled linens were properly handled and failed to ensure proper hand sanitation during wound treatments. This affected two (#2 and #62) of four residents reviewed for infection control measures during care and services. The census was 58. Findings include: 1. Review of Resident #2's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident # 2 include hypertension, cerebral vascular accident affected right side, heart disease, diabetes, and anxiety disorder. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed Resident #2 had intact cognition and was dependent for toileting and hygiene assistance. Observation on 08/19/25 at 10:27 A.M. of Certified Nurse Aide (CNA) #90 revealed the CNA exiting Resident #2's room with both arms and hands ungloved carrying uncovered linens, which were touching CNA #90's body. She carried the linens…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-25 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to obtain written documentation in the medical record of the code status of one (#41) resident of three residents reviewed for advance directives. The facility census was 58.Findings include:Review of the medical record revealed Resident #41 was admitted to the facility on [DATE]. Diagnoses included type two diabetes mellitus without complications, severe sepsis without septic shock, cellulitis, rheumatoid arthritis, and atrial fibrillation. Review of Resident #41's admission summary dated [DATE] revealed the resident was alert and a full code (initiate cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest). Review of a physician order dated [DATE] revealed Resident #41 had an advance directive for Do Not Resuscitate Comfort Care (DNRCC; meaning no CPR will be performed for cardiac or respiratory arrest and only comfort care measures will be initiated).Review of a physician progress note dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-25 · 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, review of self-reported incidents, staff interview, and review of a policy, the facility failed to timely report an allegation of abuse. This affected one (#23) of one residents reviewed for abuse. The facility census was 58. Finding include: Review of Resident #23's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included hemiplegia, cerebral infarction accident, history right hip fracture, seizure disorder, and hypertension. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed Resident #23 had intact cognition and required moderate staff assistance with bathing. Review of a self-reported incident (SRI) dated 08/18/25 revealed, during the annual survey, Resident #23 alleged abuse during personal care of a previous incident in March 2025. During the investigation, Certified Nurse Aide, (CNA)# 133 stated earlier in the month of August 2025 , Resident #23 reported to her an unnamed CNA said, You understand this,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, medical record review, and review of a facility policy, the facility failed to ensure fall incidents were reviewed and interventions put in place in a timely manner and failed to ensure established fall interventions were in place as care planned. This affected two (#25 and #64) of six residents reviewed for falls. The census was 58. Findings include:1. Medical record review for Resident #25 revealed she was admitted to the facility on [DATE]. Her diagnoses included, major depressive disorder, essential primary hypertension, generalized anxiety, hallucinations, bipolar disorder, insomnia, anemia, anorexia nervosa, and candidal esophagitis. Review of the Minimum Data Set (MDS) assessment, dated 07/02/25, revealed Resident #25 was cognitively intact. Resident #25 was dependent on staff for medication administration, lower body dressing, and putting on/taking off shoes. Resident #25 required supervision with meals and oral hygiene. Resident #25 required maximum assistance from…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-25 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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, resident and staff interview, medical record review, and review of a facility policy, the facility failed to ensure incontinence care was provided timely and adequately. This affected two (#4 and #41) of two residents reviewed for bowel and bladder. The census was 58.Findings include:1. Medical record review for Resident #4 revealed an admission date of 05/16/23. Medical diagnoses included pneumonia meningitis, ulcerative colitis, and viral hepatitis.Review of the care plan dated 01/20/25 revealed Resident #4 was at risk for bladder incontinence related to impaired mobility. Interventions included to clean the peri-area after each incontinence episode, and wash, rinse, and dry after each incontinence episode. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was cognitively intact. His functional status was supervision or touching assistance for eating, and was dependent for toileting, bed mobility, and transfers. He was frequently incontinent for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-25 · tag F0725 — failed to have enough nursing staff — isolatedProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
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, resident and staff interview, and medical record review, the facility failed to ensure the facility was adequately staffed to provide timely care and services for residents. This affected one (#41) of two residents reviewed for bowel and bladder. The census was 58. Findings include:Review of the medical record revealed Resident #41 was admitted to the facility on [DATE]. Diagnoses included type two diabetes mellitus without complications, severe sepsis without septic shock, cellulitis, rheumatoid arthritis and atrial fibrillation. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 had no behaviors, did not reject care, and did not wander. The resident was dependent for toileting, required substantial assistance with bathing, and was dependent for transfers. Review of the care plan for Resident #41 dated 08/16/25 revealed the resident was frequently incontinent of bladder and bowel. Interview and observation with Resident #41 on 08/20/25 at 8:52…
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 before2024-03-28 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, staff interviews, and policy review, the facility failed to perform appropriate hand hygiene while preparing food for residents. This affected four (#13, #20, #21, and #22) of six residents sampled for food preparation. The facility census was 58. Findings include: 1. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] and had diagnoses including unspecified epilepsy and stage III chronic kidney disease. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #13 had moderately impaired cognition, had no behaviors, did not wander, and did not reject care. 2. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] and had diagnoses including type II diabetes and vascular dementia. Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #20 was cognitively intact, had no behaviors, did not wander, and did not reject care. 3. Review of the medical…
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 · E2023-05-01 · tag F0758 — failed to limit and justify psychotropic drugs — patternImplement 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 record reviews, staff interviews, and review of on line medication guidance, the facility failed to ensure as needed (prn) psychotropic medications were not prescribed for longer than 14 days and failed to ensure psychotropic medications were only used for appropriate indications. This affected five residents (#5, #11, #21, #34, and #39) out of the six residents reviewed for unnecessary medications and hospice services. The facility census was 57. Findings include: 1. Record review for Resident #5 revealed this resident was admitted to the facility on [DATE] and had diagnoses including depression and anxiety. Review of the significant change Minimum Data Set (MDS) assessment, dated 04/01/23, 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 transfers, bed mobility, and toileting. This resident was assessed to receive hospice…
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 · E2023-05-01 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, resident and staff interviews, and review of the menu, the facility failed to provide food portions as approved by a Registered Dietitian and offer food choices. This affected thirteen residents, (#11,#10,#09,#16,#19,#02,#36,#15,#48,#33,#40,#47, and #216) of 55 residents who received food from the kitchen. The total facility census was 57. Findings Include: 1. Review of the Resident #33 chart revealed Resident #33 admitted to the facility on [DATE] with diagnoses including hemiplegia, anorexia nervosa, gastro- esophageal reflux disease, vitamin D deficiency and iron deficiency anemia. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition and the physician ordered a regular pureed texture with nectar thick liquid diet. Review of the breakfast meal menu on 04/26/23 for House #9 revealed the 04/26/23 breakfast menu posted on the kitchen refrigerator consisting of one doughnut, two eggs, one cup of cereal, four…
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 before2023-05-01 · 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 obtain and document dishwasher and food temperatures, failed to label and date foods, and discard expired foods. This had the potential to affect 55 residents who receive food from the kitchen. The facility census was 57. Findings include: Review of April 2023 dishwasher logs of House #9 and House #10 revealed multiple days of no documentation of dishwasher temperatures. For April 2023 log of House # 9, only temperatures on 04/02/23 and 04/03/23 were completed. For April 2023 log of House #10, only 04/15/23 temperature was documented. Review of food temperatures logs for House #9 revealed 49 meal temperatures from 04/01/23 through 04/25/23 were not documented. Observation on 04/24/23 at 8:20 A.M. revealed following kitchen sanitation violations in House 15: 1. Package of open meat dated 04/06/23. 2. Reach in refrigerator with no internal thermometer. 3. Torn uncovered package raw meat exposing raw meat and blood in the refrigerator compartment. 4. Refrigerator temperature log not completed for month 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 · D2023-05-01 · 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 record reviews and staff interviews, the facility failed to ensure a significant change Preadmission Screening and Resident Review (PASARR) was completed after residents received new mental health diagnoses. This affected two residents (#3 and #23) out of the three residents reviewed for PASARR's during the annual survey. The facility census was 57. Findings include: 1. Record review for Resident #23 revealed this resident was admitted to the facility on [DATE] and had diagnoses including major depressive disorder and anxiety disorder and had a diagnosis of unspecified psychosis added on 09/22/22. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/24/23, revealed this resident had mildly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 10 out of 15. This resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, and toileting. Further record review for Resident #23 revealed the last PASARR…
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 · D2023-05-01 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to complete an initial baseline plan of care to include fluid restrictions and daily weights monitoring for three Residents ( #216, #214 and #212 ) of three residents reviewed for baseline care plans. The facility census was 57. Findings Include: 1. Record review of Resident #216 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #216 included dysphagia, malignant carcinoid tumor of rectum, atherosclerotic heart disease, hypertension, and chronic obstructive pulmonary disease. Review of the initial admission assessment dated [DATE] revealed the resident had intact cognition. Physician orders, dated on admission of 04/19/23, revealed orders for Regular soft and bite sized texture diet, ice chips, and fluid restriction 1000 milliliters a day. Review of the initial base line plan of care dated 04/20/23 revealed no initial risk assessment, goals, and interventions to address the physician ordered fluid restriction of 1000…
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 · D2023-05-01 · 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 reviews, interviews, and review of online guidance, the facility failed to ensure hospital discharge instructions were ordered and implemented, failed to ensure surgical follow-up appointments were made, failed to ensure surgical wounds received adequate monitoring and treatment, and failed to ensure adequate care of a Portacath (an implanted venous access device). This affected one resident (#21) identified as having an implanted Portacath device and one resident (#24) who returned from the hospital after surgical intervention of a hip fracture. The facility census was 57. Findings include: 1. Record review for Resident #21 revealed this resident was admitted to the facility on [DATE] and had diagnoses including anxiety disorder, adjustment disorder, and presence of other specified devices. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/23/23, revealed this resident had intact cognition evidenced by a BIMS assessment score of 15 out of 15. This resident was assessed 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 · D2023-05-01 · 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 record review, staff interview, and policy review, the facility failed to monitor fluid restrictions and daily weights as ordered by the physician for three residents (#216, #214 and #212) of four residents reviewed for fluid restrictions and daily weights. The facility census was 57. Findings Include: 1. Record review of Resident #216 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #216 included dysphagia, malignant carcinoid tumor of rectum, atherosclerotic heart disease, hypertension, and chronic obstructive pulmonary disease. Review of the initial admission assessment dated [DATE] revealed the resident had intact cognition. Physician orders, dated on admission of 04/19/23, revealed orders for Regular soft and bite sized texture diet, ice chips, and fluid restriction 1000 milliliters a day. Record review of Resident #216 weight log from 04/19/23 to 04/24/23 revealed a weight increase of 4.4 pounds. Review of Medication Administration Record, (MAR) dated April 2023…
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 · F2020-02-06 · tag F0730 — widespreadObserve each nurse aide's job performance and give regular training.
What the surveyor found here — the official record, unedited, may be distressing
Based on personnel record review and staff interview, the facility failed to ensure three State Tested Nursing Assistants (STNAs) of five reviewed received at least 12 hours of on-going training annually. This had the potential to affect all 42 residents of the facility. Findings include: 1. Review of STNA #223's personnel file revealed the STNA had a hire date of 10/14/16. There was no evidence the STNA received 12 hours of ongoing training annually. 2. Review of STNA #221's personnel file revealed the STNA had a hire date of 01/31/17. There was no evidence the STNA received 12 hours of ongoing training annually. 3. Review of STNA #214's personnel file revealed the STNA had a hire date of 06/28/16. There was no evidence the STNA received 12 hours of ongoing training annually. Interview on 02/04/20 at 1:11 P.M. with Human Resource Supervisor (HR) #217 confirmed STNA #223, #221 and #214 had not completed twelve hours on on-going training and in-services.
- Potential for harm · D2020-02-06 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to timely respond to pharmacy recommendations. This affected one Resident (#35) of five residents reviewed for unnecessary medications. The facility census was 42. Findings include: Medical record review revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including thrombocytopenia, emphysema, and pulmonary embolism. Review of Resident #35's physician order dated 04/05/19 revealed an order for Diazepam, five milligrams (mg.), one-half tablet, as needed (PRN) every 24 hours for breakthrough muscle spasms and tremors. The physician order additionally directed the order would be evaluated and monitored every 14 days for continued use. Review of Resident #35's pharmacy recommendation dated 06/14/19 revealed the prescriber must provide documentation in the resident's medical record with a rationale and a specific period of time for the Diazepam to continue. There was no evidence the physician reveiwed or responded to 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.
“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 OTTERBEIN SENIORLIFE — 20 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 | 1 of 5 | 3.2 | -2.2 vs chain |
| Health inspection | 2 of 5 | 3.0 | -1.0 vs chain |
| Staffing | 1 of 5 | 3.2 | -2.2 vs chain |
| Quality measures | 3 of 5 | 4.1 | -1.1 vs chain |
The other 19 homes this chain runs (chain average 3.2★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| OTTERBEIN NEIGHBORHOODS, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 01/01/2016 |
| OTTERBEIN HOME | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 100% | since 12/01/2021 |
| ARNOLD, DANIEL | Individual | CORPORATE OFFICER | — | since 09/03/2018 |
| GREEN, JAMES | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 11/21/2005 |
| WILSON, JILL | Individual | CORPORATE OFFICER | — | since 05/01/2009 |
| FUNCTIONAL PATHWAYS OF TENNESSEE LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/04/2025 |
| APP, LYNN | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2021 |
| BARTLETT, VICTORIA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2021 |
| BAYLIFF, BECKY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2021 |
| BROWNSON, WILLIAM | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2021 |
| BURKE, DANIEL | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2021 |
| COLEMAN, ROBERT | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2021 |
| DAMICO, MADELINE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/06/2019 |
| FRALEY, RALPH | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2021 |
| GLOSSER, HEIDI | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2021 |
| HAWKINS, RITA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 08/17/2015 |
| HAZELBAKER, TOMAS | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2021 |
| VONDERHAAR, STEVE | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2021 |
| BAKER, STEVE | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 04/04/2025 |
| GALBUT, ABRAHAM | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 04/04/2025 |
| GALBUT, DANIEL | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 04/06/2025 |
| GALBUT, DAVID | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 04/04/2025 |
| GALBUT, ERIC | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 04/06/2025 |
| GALBUT, ROBERT | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 04/04/2025 |
| PARITZKY, JONATHAN | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 04/04/2025 |
| ROMBRO, DAVID | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 04/04/2025 |
| ZISEK, TODD | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 04/04/2025 |
| POLARIS PHARMACY SERVICES OF OHIO LLC | Organization | ADP OF THE SNF | — | since 12/01/2018 |
| CHINTA, VIJAYALAKSHMI | Individual | ADP OF THE SNF | — | since 12/01/2021 |
CMS files one row per role, so the 34 rows in the source record cover these 29 parties — each is shown once here with every role it holds. Nothing is omitted.
4 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.
This home reported $376K 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 366445. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-25, 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.