Avenue At Macedonia
9730 Valley View Road, Macedonia, OH 44056 · For profit - Corporation · 98 certified beds · (330) 748-8800 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- it has an abuse, neglect, or exploitation citation (F0600), cited Jan 2025
- 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 2 actual-harm citations
- a high number of inspection citations overall (34) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $23,140 in federal fines (most recent 2024-11-14)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- about 19% of its spending goes to commonly-owned related companies
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) | Not rated |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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 | 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 improved from 1 to 2 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 | 4.3% | 6.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.2% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.7% | 0.4% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 52.7% | 30.1% | 6.5% | worse 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 | 4.6% | 3.2% | 3.3% | worse |
| 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 | 23.9% | 25.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 83.3% | 94.5% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 3.2% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 23.4% | 21.4% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 8.0% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.5% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 40.4% | 75.6% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 24.1% | 24.9% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 16.5% | 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.
47.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 116 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 62.5% 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 32 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 0.26 therapist hours per resident per day in 2026Q1 — more than 38% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 9% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 47.2%CMS range 40.3–56.0 | 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 | 12.7%CMS range 9.3–16.9 | 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 | 62.5% | 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 | 56.2% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 56.2% | 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 | 95.9% | 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 | 2.0% | 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 | 2.0% | 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 | 8.1%CMS range 4.5–13.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.04 | 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
CMS has not published payroll-based (PBJ) staffing hours for this facility yet — this can happen for newer, hospital-based, or recently-certified homes. It can also mean the home simply did not file, which CMS does not distinguish in this data, so treat the gap as unexplained rather than benign. Staffing is one of the three parts of the CMS star rating; where it’s missing, weigh the independent health-inspection score most, and ask the facility directly about its nurse-to-resident ratios and weekend RN coverage.
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.
34 citations, most serious first. The 12 most serious are shown; the remaining 22 are one tap away and print in full.
- Actual harm · Gcited before2024-11-14 · 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, facility policy review and interview, the facility failed to provide timely and necessary care/treatment for Resident #100 and Resident #102 following identified changes in condition. Actual Harm occurred beginning on 10/09/24 when Resident #100, who was severely cognitively impaired was noted by direct care staff (Certified Nursing Assistant 3249) to be favoring her right side, had bruising noted and wasn't right without evidence a licensed nurse assessed the resident or provided necessary intervention. On 10/11/24 licensed staff documented Resident #100 was sitting awkwardly in her chair and guarding her upper right side thigh area. Between 10/11/24 and 10/14/24 the resident exhibited signs of increased pain (facial grimacing and guarding of the leg) with an inability to obtain an x-ray of the area (due to positioning issues). On 10/14/24 (five days after the initial change was identified) the resident was transferred to the hospital and diagnosed with a right hip fracture 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.
- Actual harm · G2022-10-24 · 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 observation, interview, record review and review of facility policy the facility failed to ensure one resident (Resident #54) did not develop an unstageable pressure ulcer of the sacrum. Actual Harm occurred when Resident #54 who was re-admitted to the facility on [DATE] for rehabilitation following surgery for a left hip fracture developed a sacral pressure ulcer that was not identified until it was unstageable. This affected one resident (Resident #54) out of three residents reviewed for pressure ulcers. The facility census was 57. Findings include: Review of Resident #54's medical record revealed an admission date of 03/16/18 and diagnoses included Alzheimer's disease, dementia, and urinary incontinence. Review of Resident #54's physician orders dated, 03/16/18, revealed turn and reposition frequently while in bed as tolerated every shift. Review of Resident #54's care plan dated 03/17/18, revealed Resident #54 had the potential for pressure ulcers, skin breakdown related to Alzheimer's disease,…
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 before2025-02-27 · 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, record review, interview, and facility policy review, the facility failed to implement and follow transmissions based precautions (TBP) and enhanced barrier precautions (EBP) as required. This affected three residents (Residents #5, #73 and #195) of five reviewed for TBP. The facility identified four residents (Residents #52, #60, #64 and #72) on droplet TBP and 14 residents (Residents #2, #3, #5, #6, #12, #14, #30, #39, #41, #46, #56, #69, #80 and #89) on EBP. The facility census was 88. Findings include: 1. Review of the medical record for Resident #73 revealed an admission date of 06/13/23. Diagnoses included diabetes, hypertension, depression, dementia and kidney disease. Review the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #73 was severely cognitively impaired. Resident #73 required setting up for eating, partial to moderate assistance for oral hygiene and substantial or maximum assistance for toileting and showering. Review of the 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 · E2025-02-27 · tag F0887 — patternEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview the facility failed to maintain documentation the COVID-19 vaccine was offered to residents and residents were provided education regarding the benefits and risks associated with the COVID-19 vaccine annually. This affected four Residents (Residents #1, #31 #42 and #76) of five reviewed for immunizations. The census was 88. Findings include: Review of the medical record for Resident #1 revealed an admission date of 12/11/21. There was no evidence Resident #1 had been offered or educated regarding the COVID-19 vaccination within the past year. Review of the medical record for Resident #31 revealed an admission date of 09/04/19. There was no evidence Resident #31 had been offered or educated regarding the COVID-19 vaccination within the past year. Review of the medical record for Resident #42 revealed an admission date of 07/30/20. There was no evidence Resident #42 had been offered or educated regarding the COVID-19 vaccination within the past year. Review of the medical record for Resident #76 revealed an admission date of 04/14/23. There was no…
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 · D2025-02-27 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interviews, the facility failed to ensure call lights were within reach for Residents #6 and #8. This affected two residents (#6 and #8) of five observed for accommodation of needs. The facility census was 88. Findings include: 1. Review of the medical record for Resident #6 revealed an admission date of 11/29/24 with diagnoses including multiple sclerosis (disease that affects the central nervous system which causes numbness, weakness, difficulty walking, vision changes and other symptoms) and contractures. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had severe cognitive impairment. She was dependent on staff for oral care and hygiene. Review of the care plan dated 06/07/19 for Resident #6 revealed she had self-care performance deficit for activities of daily living related to limited mobility and contractures. Interventions revealed she was dependent on one staff for activities of daily living and the staff were 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 · D2025-02-27 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation and interview, the facility failed to maintain resident rooms in a clean and sanitary manner. This affected one (Resident #41) of two residents reviewed for enteral feedings. The facility census was 88. Findings include: Review of the medical record for Resident #41 revealed an admission date of 12/19/23 with diagnoses including hemiplegia (paralysis on one side of the body) and gastrostomy. Observation of Resident #41's room on 02/25/25 at 8:23 A.M. revealed there was yellowed dried enteral feeding on the floor and on the feeding tube pole. Observation on 02/25/25 at 9:58 A.M. revealed yellow dried enteral feeding on the floor by Resident #41's bed and on the feeding tube pole. Observation of Resident #41's room on 02/25/24 at 1:25 P.M. revealed the trash can was empty with no trash bag liner currently in place and there was thick yellow dried enteral feeding on the bottom of the can. There was dried tube feeding also noted to Resident #41's tray table, the bottom of the tray table, on the floor under the tube feeding pole and on the tube feeding…
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 · D2025-02-27 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure resident assessments were completed as required and/or accurate. This affected two (Resident #79 and Resident #197) of 27 residents reviewed for Minimum Data Set (MDS) 3.0 assessments. The facility census was 88. Findings include: 1. Review of the medical record for Resident #79 revealed an admission date 07/08/23 with diagnoses including Alzheimer's disease, anxiety and hypertension. Resident #79 was discharged to the hospital on [DATE] and did not return to the facility. Review of Resident #79's MDS assessments revealed she had a quarterly assessment on 10/01/24. There were no assessments completed after that date. Interview on 02/25/25 at 10:37 A.M. with Registered Nurse (RN) #526 verified she had not completed a discharge return not anticipated MDS assessment for Resident #79 after she was discharged and did not return to the facility. 2. Review of the medical record for Resident #197 revealed an admission date of 07/15/24 with diagnoses…
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 before2025-02-27 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services for incontinence care, oral hygiene, and feeding assistance. This affected three (Residents #6, #56 and #59) out of four residents reviewed for ADL assistance. The facility census was 88. Findings include: 1. Review of the medical record for Resident #6 revealed an admission date of 11/29/24 with diagnoses including multiple sclerosis (disease that affects the central nervous system which causes numbness, weakness, difficulty walking, vision changes and other symptoms) and contractures. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had severe cognitive impairment and was dependent on staff for oral care and hygiene. Review of Resident #6's care plan dated 12/01/24 revealed she had self-care performance deficit for activities of daily living related to limited 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 before2025-02-27 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation, and interviews the facility failed to ensure Vancomycin (antibiotic) levels were monitored. This had the potential to affect one (Resident #195) of one resident reviewed for Vancomycin administration. The facility census was 88. Findings include: Review of medical record for Resident #195 revealed an admission date of 02/19/25 with diagnoses including bacteremia and streptococcal polyarthritis (inflammatory joint condition). Review of the physician's orders for Resident #195 for February 2024 revealed an order for Vancomycin intravenous solution 500 milligrams (mg), use 1.75 grams intravenously every 12 hours at 8:00 A.M. and 8:00 P.M. for 22 days dated 02/20/25. There were no laboratory orders to monitor for Vancomycin levels to ensure appropriate levels and efficacy. Observation and interview on 02/25/25 at 12:00 P.M. revealed Licensed Practical Nurse (LPN) #556 administering Vancomycin to Resident #195. After administration, LPN #556 was unable to state how the facility was monitoring the Vancomycin serum levels. Interview on 02/26/25 at 11:10…
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 · D2025-02-27 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents received recommended ancillary services. This affected one resident (Resident #47) of three reviewed for vision and hearing. The census was 88 residents. Findings include: Review of the medical record for Resident #47 revealed an admission date of 05/30/22. Diagnoses included kidney disease, diabetes, heart failure, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 was cognitively intact. Resident #47 required set up help for eating and oral hygiene, partial to moderate assistance for showering and personal hygiene and was dependent for toileting. Resident #47's vision was adequate and she did not have corrective lenses. Interview on 02/24/25 at 9:43 A.M. with Resident #47 revealed she had a cataract and the facility had not assisted her in setting up an appointment for surgery. Review of the optometrist note dated 03/13/24 revealed Resident #47 had cataracts which were…
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 · D2025-02-27 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
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, and interview the facility failed to ensure Resident #15's enteral feeding was delivered per the physician's orders. This affected one (Resident #15) of one resident reviewed for enteral feedings. The facility census was 88. Findings include: Review of the medical record for Resident #15 revealed an admission date of 12/13/22 with diagnoses including cerebral palsy (condition that affects movement and posture) and gastrostomy status. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was dependent on staff for eating and received 51 percent (%) of his total calories through tube feeding. Review of the physician's orders for Resident #15 revealed an order for enteral feeding at 70 milliliters (mL) per hour, up at 11:00 P.M. and down at 11:00 A.M. dated 02/20/25. Review of the Medication Administration Record (MAR) for February 2025 for Resident #15 revealed the nurse had documented on 02/25/25 for the 6:00 A.M. to 6:00 P.M. shift…
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 · D2025-02-27 · 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 review, interview, and observation the facility failed to ensure safety measures were in place to prevent a fall. This affected one resident (#107) of three residents (#5, #31 and #197) reviewed for falls. The census was 88. Findings include: Review of the medical record for Resident #197 revealed an admission date of 07/15/24. Diagnoses included Alzheimer's disease, diabetes, essential hypertension and dementia with other behavioral disturbance. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #197 was cognitively impaired and was dependent for transfers. Review of Resident #197's care plan dated 07/26/23 and last revised on 01/13/25 revealed a goal to minimize risks for falls and to minimize injuries related to falls. Interventions included implementing preventative fall interventions/devices and to rearrange furniture. Review of the fall investigation dated 01/05/25 timed 6:27 P.M. revealed Resident #197 was observed with head, shoulders and torso…
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 22 citations
- Potential for harm · Dcited before2025-01-22 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of a facility self-reported incident and investigation, personnel file review, facility policy review, Centers for Medicare and Medicaid guidance and interview, the facility failed to ensure an employee (Laundry Aide #201) did not engage in an inappropriate relationship with Resident #91 which had the potential to be considered an abuse of power and resulted in an allegation of staff to resident sexual abuse reported by the resident. This affected one resident (#91) of three residents reviewed for abuse. The facility census was 92. Findings include: Review of the medical record for Resident #91 revealed an admission date of 04/05/22 with diagnoses including emphysema, diabetes, alcohol abuse, depression, hypertension and history of right arm fracture. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #91 was cognitively intact. The assessment revealed the resident had hallucinations, delusions or behaviors and was independent in all activities of daily…
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 · D2024-11-14 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and facility policy review, the facility failed to ensure Resident #62 received quarterly care conferences. This affected one resident (Resident #62) out of three residents reviewed for care plan conferences. Census was 89. Findings include: Record review revealed Resident #62 was admitted to the facility on [DATE] with diagnosis included but not limited to Alzheimer's Disease, Dementia, adult failure to thrive, and delusional disorders. Review of the quarterly Minimum Data Set (MDS) assessment completed on 09/10/24 revealed Resident #62 had severely impaired cognition. Revealed Resident #62's Care Plan Conference Summary Forms revealed a care plan meeting was held on 05/30/23, 11/02/23, 02/01/24, and 04/18/24. Interview on 10/28/24 at 1:30 P.M. with Social Service Designee (SSD) 268 revealed care conference should be completed upon admission within the first five days then quarterly, annually, with significant changes, or if family/resident wants sooner. SSD #268 confirmed…
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 · D2024-07-29 · 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 review of the medical record and interview with staff the facility failed to ensure the comprehensive care plan for Resident #95 included hearing impairment and need for sign language as her primary means of communication with the facility. This affected one resident ( Resident #95) of three residents reviewed for care plans. The facility census was 90. Findings included: Review of the medical record revealed Resident #95 was admitted to the facility on [DATE]. Diagnoses included staphylococcal arthritis of the left knee, esophageal varices, endocarditis, diabetes, cirrhosis of the liver, osteomyelitis of the vertebrae, discitis, chondrocalcinosis, cervicalgia, migraines, deaf and nonspeaking. She was discharged on 07/03/24. Review of the document titled Referral Information, dated 05/22/24, sent by Cleveland Clinic hopsitals to the facility for Resident #95 revealed the referral comments stated patient is deaf. Do you have ability to provide access to a video remote interpreter for sign language or an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-29 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the medical record and interview with the staff the facility failed to ensure the facial hairs on dependent Resident #48 were removed. This affected one resident ( Resident #48) of three residents reviewed who were dependent for care and services. The facility census was 90. Findings included: Review of the medical record revealed Resident #48 was admitted to the facility on [DATE]. Diagnoses included dementia, viral hepatitis C, dysphagia, major depressive disorder, and irritable bowel syndrome. Review of the care plan dated 08/07/23 with a revision date of 04/19/24 revealed Resident #48 had behaviors including crawling on the floor, purposely placing herself on the floor, verbal aggression, yells out at times, takes clothes off and throwing them, taking her brief off, and racial slurs. Interventions included to provide a calm, safe environment when the residents frustration escalate and allow her time to voice her feelings, give nonjudgmental support, offer support to identify…
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 · D2024-02-13 · tag F0557 — isolatedHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview the facility failed to ensure Resident #1 was treated with dignity and respect. This affected one resident (#1) of three residents reviewed for resident rights. The facility census was 86. Findings Include: Review of the medical record for Resident #1 revealed an admission date of 09/18/23. Diagnoses included acute and chronic respiratory failure with hypoxia, type two diabetes mellitus, and injury to sacral spinal cord. The resident was cognitively intact. Interview on 02/07/24 at 1:30 P.M. with Resident #1 revealed State Tested Nursing Assistant (STNA) #220 spoke to him in a disrespectful manner a few weeks prior. He stated he put his call light on, and when STNA #220 answered it, she responded, Seriously, that's what you called me in here for? then shut the door loudly after she completed the task. Resident #1 stated he did not feel he was abused but rather felt it was a matter of customer service and lack of dignity and respect. He stated he reported it to the Director of Nursing (DON) immediately. He was satisfied with the DON educating STNA…
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 before2024-01-04 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure Resident #53 was free from verbal abuse. This finding affected one (Resident #53) of three residents reviewed for abuse. Findings include: Review of Resident #53's medical record revealed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including Alzheimer's disease, vascular dementia and anxiety disorder. Review of Resident #53's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of an Emotional/Verbal Abuse Self-Reported Incident (SRI) Form Tracking #241367 dated 11/20/23 revealed on 11/17/23 at approximately 1:45 P.M., the Hospice State Tested Nursing Assistant (STNA) #810 asked Licensed Practical Nurse (LPN) #811 (facility staff) to assist her with care for the resident. While performing the care, Resident #53 started getting verbally and physically aggressive with the nurse. The nurse continued to assist the STNA with care but got…
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 · D2024-01-04 · 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 record review and interview, the facility failed to timely report an allegation of verbal abuse. This finding affected one (Resident #53) of three residents reviewed for abuse. Findings include: Review of Resident #53's medical record revealed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including Alzheimer's disease, vascular dementia and anxiety disorder. Review of Resident #53's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of an Emotional/Verbal Abuse Self-Reported Incident (SRI) Form Tracking #241367 dated 11/20/23 revealed on 11/17/23 at approximately 1:45 P.M., the Hospice State Tested Nursing Assistant (STNA) #810 asked Licensed Practical Nurse (LPN) #811 (facility staff) to assist her with care for the resident. While performing the care, Resident #53 started getting verbally and physically aggressive with the nurse. The nurse continued to assist the STNA with care but got…
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 before2024-01-04 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure a medication error rate of less than 5% (percent). A total of 34 medications were observed with six errors for a medication error rate of 17.64%. This finding affected two (Residents #3 and #53) of three residents observed for medication administration. Findings include: 1. Review of Resident #3's medical record revealed the resident was admitted on [DATE] with diagnoses including schizophrenia, chronic obstructive pulmonary disease and dementia. Review of Resident #3's physician orders revealed an order dated 07/20/23 for Aspirin 81 mg (milligrams) oral tablet chewable give one tablet by mouth one time a day for heart health; an order dated 07/20/23 for Folic Acid oral tablet one mg give one tablet by mouth one time a day for health maintenance; an order dated 07/20/23 for Calcium Carbonate-Vitamin D oral tablet 600-10 mg-mcg (micrograms) give one tablet by mouth two times a day for low calcium; and an order dated 07/20/23 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 · Dcited before2024-01-04 · tag F0803 — failed to meet residents' dietary needs — isolatedEnsure 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 observation, record review and interview, the facility failed to ensure Resident #42 and Resident #53 were served food items per the dietary menu and meal ticket. This finding affected two (Residents #42 and #53) of three residents reviewed for meals. Findings include: 1. Review of Resident #42's medical record revealed the resident was admitted on [DATE] with diagnoses including autistic disorder, quadriplegia and epilepsy. Review of Resident #42's physician orders revealed an order dated 02/09/23 for a regular diet, pureed texture with a thin liquids consistency for pleasure. Review of Resident #42's breakfast meal ticket dated 01/02/24 indicated the beverage was water, a banana and yogurt with the pureed meal. Observation on 01/02/23 at 8:38 A.M. revealed Resident #42's breakfast meal tray was sitting on his overbed table by the wall out of reach of the resident. Observation on 01/02/24 at 8:49 A.M. revealed State Tested Nursing Assistant (STNA) #809 came in to assist the resident with the breakfast…
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 before2023-10-12 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, and record review the facility failed to ensure the proper serving size was provided for the main lunch entrée. This affected five residents (#3, #16, #17, #18, and #73) of five residents who received the main lunch entrée in the dining room. The facility census was 82. Findings include: Review of the menu extension dated 10/11/23 revealed lunch included an eight ounce spoodle of cheese tortellini alfredo, four ounce spoodle drained of seasoned Italian green beans, and one slice of cheesy garlic toast. Observation of tray line on 10/11/23 at 11:45 A.M. revealed Dietary [NAME] (DC) #409 plating the lunch meal for the residents in the dining room. DC #409 served the tortellini using a green handled spoon providing one scoop per plate. Interview on 10/11/23 at 11:54 A.M. with Corporate Registered Dietitian (CRD) #408 revealed the green handled spoon served four ounces. CRD #408 verified the serving for the tortellini was supposed to be eight ounces and DC #409 served four ounces of tortellini using the green handled spoon. Observation in 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 · F2022-10-24 · tag F0814 — failed to dispose of garbage properly — widespreadDispose of garbage and refuse properly.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview the facility failed to ensure garbage was disposed of properly. This had the potential to affect all residents in the building. Facility census was 57. Finding include: During initial tour of the kitchen on 10/17/22 at 10:58 A.M. with Dietary Manager #904 observation revealed the garbage dumpster had an open door. There was a pile of boxes beside dumpster on a cart and bag of mixed garbage beside the dumpster. Interview on 10/17/22 at 11:05 A.M. with Dietary Manager #904 verified the garbage was not disposed of properly.
- Potential for harm · Dcited before2022-10-24 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review and review of facility policy the facility failed to ensure two resident's (Resident's #30 and #63) received assistance with activities of daily living (ADL). This affected two resident's (Resident's #30 and #63) out of three residents reviewed for ADLs. The facility census was 57. Findings include: Review of Resident #30's medical record revealed an admission date of 05/30/22 and diagnoses including periprosthetic fracture around internal prosthetic right knee joint, type two diabetes mellitus and major depressive disorder. Review of Resident #30's care plan dated, 09/13/22, revealed Resident #30 had ADL functional rehabilitation potential. Resident #30 would achieve maximum functional mobility. Interventions included ambulation, transferring assist of two; bathing, hygiene assist of two. Resident #30 was resistive at times and refused care related to bathing, showers, help with grooming. Further review of the care plan revealed Resident #30 would be encouraged to participate in care through next review date. Interventions included 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 · D2022-10-24 · 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
Based on observation, interview, record review and review of therapy evaluation the facility failed to ensure Resident #63 wore his left hand splint per physician orders and therapy recommendations. This affected one resident (Resident #63) out of three residents reviewed for orthotic devices. The facility census was 57. Findings include: Review of Resident #63's medical record revealed an admission date of 01/04/19 and diagnoses included hemiplegia (weakness) and hemiparesis (paralysis) following nontraumatic subarachnoid hemorrhage affecting left non dominant side, nontraumatic intracerebral hemorrhage, cerebral infarction, spastic hemiplegia affecting left nondominant side. Review of Resident #63's physician orders dated, 07/15/21, revealed physician orders for Resident #63 to wear left hand splint for six to eight hours daily and check skin when removed. Review of Resident #63's Annual Minimum Data Set (MDS) 3.0 assessment dated , 10/04/22 revealed Resident #63 was cognitively intact and required extensive assistance of two staff for bed mobility, and total dependence on two…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-24 · 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 observation, interview, record review and review of facility policy the facility failed to ensure two residents (Residents #1 and #30) were provided assistance with feeding and failed to ensure weekly weights were obtained. This affected two residents (Residents #1 and #30) out of three residents reviewed for nutrition. The facility census was 57. Findings include: Review of Resident #30's medical record revealed an admission date of 05/30/22 and diagnoses included periprosthetic fracture around internal prosthetic right knee joint, type two diabetes mellitus and major depressive disorder. Review of Resident #30's weights revealed 05/30/22, 05/31/22, 06/16/22 and 06/22/22 were struck out and documented as incorrect documentation. Resident #30's weight on 06/30/22 was 186.2 pounds. Resident #30's weight on 10/10/22 was 142 pounds. This was a significant weight loss of 23.74 percent. Further Review of Resident #30's weights revealed weekly weights were not documented on 07/21/22, 07/28/22, 08/18/22,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-10-24 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure a medication error rate of less than five percent. This finding affected three (Residents #21, #46 and #63) of five residents observed for medication administration. A total of 27 medications were administered with three errors for a medication error rate of 11.11 percent. Findings include: 1. Review of Resident #21's medical record revealed he was readmitted on [DATE] with diagnoses including type two diabetes, anemia and alcohol abuse with intoxication. Review of Resident #21's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she exhibited intact cognition. Review of Resident #21's physician orders revealed an order dated 08/06/21 for thiamine tablet 250 milligrams (mg) give one tablet by mouth in the morning for vitamin. Observation on 10/18/22 at 7:12 A.M. with Licensed Practical Nurse (LPN) #801 of Resident #21's medication administration revealed she administered eight medications including thiamine 100 mg.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-24 · tag F0805 — failed to prepare food in a form residents can eat — isolatedEnsure each resident receives and the facility provides food prepared in a form designed to meet individual 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, record review and interview, the facility failed to ensure Residents #20 and #52 received their diets as ordered. This affected two (Residents #20 and #52) of five residents reviewed for weight loss. Findings include: 1. Review of Resident #20's medical record revealed she was admitted on [DATE] with diagnoses including Alzheimer's disease with late onset, unspecified dementia with behavioral disturbance and other specified anxiety disorders. Review of Resident #20's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she exhibited a memory problem and required extensive one person assist for bed mobility, transfers, dressing, eating, toilet use and personal hygiene. She resided on the secured memory care unit. Review of Resident #20's physician orders revealed an order dated 05/04/22 for a regular diet, pureed texture with thin liquids consistency; an order dated 06/14/22 for her to be fed at every meal; and an order dated 10/04/22 for double portions at each meal every shift.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-10-24 · 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, record review and interview, the facility failed to ensure accurate medication administration records. This affected two (Residents #46 and #63) of five residents observed for medication administration. Findings include: 1. Review of Resident #46's medical record revealed she was admitted on [DATE] with diagnoses including type two diabetes, sepsis and anemia. Review of Resident #46's medication administration records (MARS) on 10/18/22 for the morning medication administration time period revealed Licensed Practical Nurse (LPN) #801 documented she administered amlodipine (for high blood pressure) 2.5 milligrams (mg), aspirin chewable 81 mg, famotidine (antacid) 20 mg, ferrousul tablet (iron) 325 mg, furosemide 40 mg, multivitamin, potassium 20 milliequivalent (meq) and saline nasal spray two sprays in both nostrils. Observation on 10/18/22 at 7:00 A.M. revealed LPN #801 administered Resident #46's insulin and no other medications were administered. LPN #801 indicated Resident #46 did not…
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 · E2019-11-14 · tag F0807 — failed to offer suitable drinks — patternEnsure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review and interview the facility failed to provide adequate accessible hydration to residents who resided on the secured dementia unit. This had the potential to affect all 21 residents (#7, #8, #11, #15, #16, #17, #18, #19, #21, #22, #27, #28, #30, #37, #58, #60, #71, #299, #323, #324 and #325) residing on the secured dementia unit. The facility census was 72. Findings include: On 11/12/19 from 9:00 A.M. to 11:30 A.M. observations on the secured dementia unit revealed two residents were observed to have drinking water in their room. Resident #27 was observed to have a glass of water. Resident #27 was observed to have water, which was dated 11/08/19 and placed on a counter approximately five feet away from the resident. On 11/12/19 at 12:15 P.M. observation of the lunch meal revealed there were 16 of the 21 residents in the dining room. Each resident was observed to receive one four ounce drink. None of the residents were offered any type of beverage alternative at the time the beverages were given. Three of the residents requested and received coffee…
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 before2019-11-14 · 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
Based on record review and interview the facility failed to ensure documentation on the treatment administration records for Resident #3, Resident #38 and Resident #48 was complete. This affected three residents (#3, #38 and #48) of six residents reviewed for treatment documentation. Findings include: 1. Review of the medical record for Resident #3 revealed an admission dated of 06/26/17 with diagnoses including Parkinson's disease, psychotic disorder and pressure ulcers. Review of the treatment administration record dated October 2019 revealed a lack of documentation for seven of thirty days related to assessing pain and wound dressing changes which were ordered to be completed every Tuesday, Thursday and Saturday. Review of the treatment administration record dated November 2019 revealed a lack of documentation for three of thirteen days related to assessing pain and wound dressing change to the coccyx every daily. During an interview on 11/14/19 at 5:00 P.M. the facility wound nurse revealed wound dressings were completed as ordered, however, the nurse verified the treatment…
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 before2019-11-14 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to maintain adequate infection control practices during incontinence care for Resident #99 to prevent the spread of infection. This affected one resident (#99) of one resident observed during incontinence care. Findings include: Record review revealed Resident #99 was admitted to the facility on [DATE] with diagnoses including vascular dementia, Alzheimer's disease, anxiety disorder and major depressive disorder. Review of the physician's orders, dated 09/20/19 revealed Resident #99 was to have bilateral floor mats every shift, (padded mats that are placed on the floor each side of the bed). Resident #99 had a care plan, dated 09/22/19 which included staff to cleanse resident after each incontinent episode. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #99 exhibited severe cognitive impairment and required extensive assistance from staff for activities of daily living. Resident #99 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.
- No harm found · C2025-02-27 · tag F0680 — widespreadEnsure the activities program is directed by a qualified professional.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of personnel files and staff interview the facility failed to ensure the activities program was directed by a qualified professional. This had the potential to affect all 88 residents. Findings include: Review of the personnel file for Activity Director (AD) #514 revealed no evidence to support AD #514 had the appropriate qualifications for holding the position of activity director. AD #514's hire date was 10/28/24. Interview and record review on 02/27/25 at 11:30 A.M. with Human Resource Director (HR) #554 revealed HR #554 was unaware of the qualifications AD #514 held for directing the activity program. A subsequent interview on 02/27/25 at 11:43 A.M. revealed AD #514 was in the process of completing a training course approved by the state. HR #554 stated the former AD, now the current Admissions Director (Admissions Director #545) still worked at the facility and trained AD #514. Review of admission Director #514's personnel file revealed admission Director #545 did not meet the qualifications to direct the activities program and had not completed a training…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2019-11-14 · tag F0625 — widespreadNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
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 provide a bed hold notice to Resident #73 as required. This affected one resident (#73) and had the potential to affect all 72 residents residing in the facility. Findings include: Record review revealed Resident #73 was initially admitted to the facility on [DATE] with diagnoses including open wound of right elbow, kidney failure, and hypertension. Resident #73's fourteen day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #73 had no cognitive impairment or indicators of depression. Review of Resident #73's progress notes dated 10/07/19 and 10/08/19 revealed Resident #73 had been refusing her medications and was discharged to the emergency room on [DATE] with both her son and daughter's knowledge. Review of Resident #73's medical record revealed no evidence a bed hold notice as provided at the time of discharge to the hospital on [DATE]. However Resident #73's admission paperwork revealed at the time of admission, Resident #73…
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
$23,140 in federal fines across 1 penalty. 1 Medicare payment denial on record.
- $23,140 — penalty dated 2024-11-14
- Medicare payment denial — starting 2025-04-06 for 4 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to PROGRESSIVE QUALITY CARE — 11 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 | 2 of 5 | 2.7 | -0.7 vs chain |
| Health inspection | 2 of 5 | 2.0 | ≈ chain avg |
| Quality measures | 4 of 5 | 4.7 | -0.7 vs chain |
The other 10 homes this chain runs (chain average 2.7★, 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 |
|---|---|---|---|---|
| FLANK, EITAN | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; ADP OF THE SNF | 20% | since 06/10/2022 |
| FLANK, LIAT | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; ADP OF THE SNF | 20% | since 06/10/2022 |
| FLANK, MATAN | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; ADP OF THE SNF | 20% | since 06/10/2022 |
| FLANK, SHAUL | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; ADP OF THE SNF | 20% | since 06/10/2022 |
| SAUSEN, JOEL | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; ADP OF THE SNF | 20% | since 06/10/2022 |
| SHILLER, DANIEL | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 03/27/2017 |
| PROGRESSIVE QUALITY CARE INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/27/2017 |
| BROCK, KATHERINE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/26/2024 |
CMS files one row per role, so the 21 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.9M paid to related parties — landlords or management companies under common ownership — equal to about 19% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
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 366454. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-02-27, 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.