Bennington Glen Nursing & Rehabilitation Center
825 State Route 61, Marengo, OH 43334 · For profit - Corporation · 79 certified beds · (419) 253-0144 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has 1 actual-harm citation
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (1/5)
- nursing-staff turnover (64%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 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 | 1 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 4 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 | 2.8% | 5.3% | 15.4% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 3.0% | 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 | 0.4% | 0.4% | 2.0% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 31.8% | 30.1% | 6.5% | typical for the 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 | 3.4% | 3.2% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 3.2% | 6.1% | 16.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 13.2% | 25.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 95.0% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.9% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 21.5% | 21.4% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 4.3% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.3% | 1.2% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 69.3% | 75.6% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 30.4% | 24.9% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 11.3% | 12.9% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 1.93 | 1.73 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.46 | 1.80 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
48.6% 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 93 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 47.6% 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 42 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 0.20 therapist hours per resident per day in 2026Q1 — more than 23% 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 | 48.6%CMS range 39.9–60.4 | 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 | 11.7%CMS range 8.2–16.3 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 47.6% | 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 | 40.5% | 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 | 45.2% | 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 | 95.5% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 95.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 93.8% | 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 | 6.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.3%CMS range 3.8–12.8 | 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 79 beds and averages 70.8 residents a day — about 90% occupied, or roughly 8 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.83 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.44 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.51 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.50 hrs/resident/day on weekends vs 2.97 on weekdays — 16% thinner on weekends. RN hours go from 0.51 to 0.27 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 64% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.
- Actual harm · Gdisputed · IDR2026-04-27 · 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 medical record review, review of the facility's investigation, staff interviews, and policy review, the facility failed to ensure Resident #6 received adequate supervision and assistance with toileting to prevent the resident from falling. Actual Harm occurred on 03/21/26 when Resident #6 was not adequately supervised in the bathroom, was left on the toilet while Certified Nurse Aide (CNA) #41 went to get new bedding and an adult brief, and Resident #6 got herself off the toilet and was coming out of the door when CNA #41 came in and saw Resident #6 fall backwards hitting her back and head on the sink, sustaining serious physical harm and injuries and was subsequently hospitalized related to rib fractures to her left seven through eleventh left ribs, a small left hemopneumothorax (accumulation of air and blood in the pleural cavity commonly caused by trauma), an acute left T9 transverse process fracture (a break in the small bony projection on the side of the ninth thoracic vertebra), and hematomas to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-27 · 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, resident interview, and staff interview, the facility failed to timely address a resident's request for accommodation of mobility needs. This affected one (Resident #7) of one resident reviewed for accommodation of needs. The facility census was 68. Findings include:Review of the medical record for Resident #7 revealed an admission date of 08/01/22. Diagnoses included contracture, bilateral primary osteoarthritis of the knee, and age-related osteoporosis without current pathological fracture.Review of the nursing progress notes revealed on 02/14/26 at 8:40 P.M., Resident #7 was lowered to the floor by staff during a transfer. The fall investigation revealed Resident #7 was lowered to the floor during a staff transfer due to the wheelchair rolling backward during transfer. The fall investigation revealed staff did lock the wheelchair but the wheelchair moved during the transfer.The nursing progress note revealed on 02/28/26 at 1:01 P.M., Resident #7 refused a shower after four attempts 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 · Ddisputed · IDR2026-04-27 · tag F0679 — failed to provide activities — isolatedProvide 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 observations, staff interviews, medical record review, review of the Resident Assessment Instrument (RAI) User's Manual, the facility failed to adequately assess the activity preferences of a resident and met the needs and preference of the resident. This affected one (#6) of two residents reviewed for activities. The facility census was 68.Findings include: Review of Resident #6's medical record revealed an admission date of 10/04/25. Diagnoses included dementia, periprosthetic fracture around internal prosthetic of left hip joint and fracture of unspecified part of neck of left femur, depression, age-related macular degeneration, osteoarthritis, and sensorineural hearing loss. Resident #6 had a niece and daughters listed as emergency contacts.Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 had a Brief Interview for Mental Score (BIMS) of six indicating she had severely impaired cognition. Resident #6 was interviewed for activity preferences and it…
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 before2026-04-27 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, medical record review, and policy review, the facility failed to ensure the physician was timely notified of the resident's, who were weighed several times a week due to a diagnosis of congestive heart failure, excess weight gain. This affected two (#19 and #45) of four residents reviewed for nutrition. The facility census was 68.Findings include:1. Review of Resident #19's medical record revealed an admission date of 09/18/25 with diagnoses including chronic heart failure (CHF). The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #19 had intact cognition.Review of Resident #19's care plan dated 09/19/25 revealed the resident had the potential for alteration in nutrition and hydration related to her diagnoses including CHF. Interventions included expected weight fluctuations related to CHF and weights according to protocol.Review of Resident #19's physician note dated 04/09/26 revealed the resident had heart failure and was complaining of having shortness…
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 · D2026-04-27 · 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
Based on observation, record review, staff interview, and review of the facility's do not crust list, the facility failed to ensure their medication error rate was less than five percent (%). There were four medication errors out of 34 opportunities resulting in a 11.76% medication error rate. This affected one (Resident #68) of five residents observed during medication administration. The facility census was 68.Findings include:Review of Resident #68's medical record revealed an admission date of 09/25/18. Diagnoses included paroxysmal atrial fibrillation, polyosteoarthritis, and gastro-esophageal reflux disease (GERD) without esophagitis.Review of Resident #68's physician orders revealed on 04/01/26, Metoprolol Succinate extended release (ER) (treats high blood pressure) oral tablet 24-hour 25 milligrams (mg) give one tablet by mouth one time a day; and Metoprolol Succinate ER oral tablet 24-hour 50 mg give one tablet by mouth one time a day for a total of 75 mg daily. On 12/04/24, an order for Pantoprazole Sodium (treats GERD) tablet delayed release 20 mg one time daily. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited beforedisputed · IDR2026-04-27 · 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 interview and medical record review, the facility failed to have accurate medical record documentation for Residents #17. The affected one (#17) of 26 residents reviewed for medical record accuracy. The facility census was 68.Findings include:Review of Resident #17's medical record revealed an admission date of 10/15/21. Diagnoses included hypothyroidism.Review of Resident #17's physician orders revealed an order for Synthroid oral tablet 175 micrograms (mcg) administer one tablet one time a day related to hypothyroidism.Review of Resident #17's Medication Administration Record (MAR) revealed no documentation for Resident #17's Synthroid oral tablet 175 mcg on 04/10/26, 04/11/26, 04/14/26, 04/15/26, and 04/16/26.The medical record did not reveal the reason why the Synthroid medication was not documented in the MAR.Interview on 04/22/2026 at 8:25 A.M. with Regional Registered Nurse #450 confirmed there was no documentation in the medical record regarding why Synthroid was not documented in Resident #17's MAR.This deficiency represents non-compliance investigated under…
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 before2026-04-27 · 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, medical record review, and staff interview, the facility failed to ensure the resident's toothbrushes were stored in a manner to maintain infection control. This affected two (#11 and #37) of 26 residents observed for infection control. The facility census was 68.Findings include:Review of Resident #37's medical record revealed an admission date of 09/29/25. Diagnoses included dysarthria and anarthria, demyelinating disease of central nervous system, and muscle weakness.Review of the Activity of Daily Living care plan dated 08/17/25 revealed Resident #37 required assistance with oral hygiene.Review of Resident #11's medical record revealed an admission date of 05/04/21. Diagnoses included dementia, chronic respiratory failure and unilateral post-traumatic osteoarthritis of first carpometacarpal joint of the left hand.Review of the Activity of Daily Living care plan dated 08/17/25 revealed Resident #11 required assistance with oral hygiene.Review of the Minimum Data Set 3.0 (MDS) assessment…
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 beforedisputed · IDR2026-04-27 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, policy review, and staff interview, the facility failed to ensure antibiotic stewardship was followed for Resident #7. This affected one (#7) of four residents reviewed for antibiotic stewardship. The facility census was 68. Findings include:Review of the medical record for Resident #7 revealed an admission date of 08/01/22. Diagnoses included chronic kidney disease.Review of the progress note revealed that on 02/26/26, Resident #7 reported burning with urination and a urine culture and sensitivity (C&S) was ordered. On 02/27/26, the urine specimen was collected that morning.Review of the urine culture results dated 02/28/26 revealed greater than 100,000 colonies per milliliter gram-negative bacilli, 10,000 to 50,000 colonies per milliliter Proteus species, and additional flora indicative of probable vaginal or urethral contamination. The report further indicated that three or more organisms were present, suggesting contamination, and stated that susceptibility testing was not recommended for contaminated urine specimens.Review of the physician orders…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-10-24 · tag F0638 — patternAssure that each resident’s assessment is updated at least once every 3 months.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure quarterly Minimum Data Set (MDS) 3.0 assessments were completed timely and as required. This affected nine residents (#14, #15, #23, #27, #30, #47, #52, #56, and #60) of 36 residents reviewed for resident assessments. The facility census was 74. Findings include 1. Review of Resident #14's medical record revealed an admission date of 05/04/21. Diagnoses included dementia. Review of Resident #14's MDS assessments revealed a quarterly assessment dated [DATE] was in progress. Resident #14's prior quarterly assessment was dated 06/01/24. The resident's MDS tab in her electronic medical record indicated the assessment was overdue. An interview on 10/22/24 at 2:54 P.M. with MDS Coordinator #393 confirmed the quarterly assessment for Resident #14 was incomplete and not completed timely. 2. Review of Resident #15's medical record revealed an admission date of 09/25/18. Diagnoses included…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-10-24 · tag F0805 — failed to prepare food in a form residents can eat — patternEnsure 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
Based on observations, staff interview, and facility policy review, the facility failed to ensure pureed food was an appropriate smooth texture prior to serving residents on a pureed diet. This had the potential to affect five residents (Residents #4, #19, #29, #34, #172) who were on a prescribed pureed diet. The facility census was 74. Findings include: Interview on 10/22/24 at 10:03 A.M. with Dietary [NAME] (DC) #344 stated she wanted the puree textures at a mashed potato consistency. DC #344 stated when the puree texture was complete, it was like baby food, which was smooth with no chunks. DC #344 said she tastes her puree food, and a resident should not have to chew a puree food item. DC #344 said there were six residents on a puree diet. DC #344 stated she was going to puree chicken enchiladas, peppers and onions, and mashed potatoes for lunch that day (10/22/24). Observation and interview on 10/22/24 at 10:08 A.M. revealed DC #344 started the chicken enchilada puree. DC #344 said the puree was done at 10:09 A.M. Observation of the puree revealed it looked chunky. DC #344 then…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-10-24 · 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 observations, policy review, review of Centers for Disease Control and Prevention (CDC) guidance, medical record review, and resident and staff interviews, the facility failed to properly do contact tracing or implement broad-based testing when staff and residents tested positive for COVID-19. The facility also failed to offer Resident #3 another room (if available) when roommate tested positive for COVID-19, and Resident #3 was not tested in a timely manner while exhibiting symptoms of COVID-19. This affected 14 Residents (#3, #6, #22, #23, #33, #35, #60, #63, #121, #171, #173, #279, #280, and #500). The facility census was 74 residents. Findings include: Review of the facility COVID-19 tracking information revealed the following positive COVID-20 cases in 27 days. On 09/26/24, Certified Nursing Assistant (CNA) #305 tested positive for COVID-19. No tracking was provided for CNA #305. On 10/01/24. Contracted Therapy/CNA #600 tested positive for COVID-19. Residents #37, #41, #44, #52, #53 #171, #174, 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.
Show the remaining 12 citations
- Potential for harm · Ecited before2024-10-24 · tag F0881 — failed to use antibiotics responsibly — patternImplement a program that monitors antibiotic use.
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, review of infection control logs, and policy review, the facility failed to implement their antibiotic stewardship program policy and thoroughly track infections to ensure infections and antibiotics were ordered appropriately. This affected 13 (#22, #27, #37, #39, #42, #54, #57, #173, #174, #175, #176, #177, and #273) of 17 residents identified as ordered antibiotics during September 2024 and October 2024. The facility census was 74. Findings include: 1. Review of the Infection Control Log dated for September 2024 revealed the facility tracked residents that had received antibiotics for the month of September 2024. The form included the resident name, admission date, onset date (of infection), site of infection, infection related diagnosis, sections to indicate whether a culture, or x-ray was performed, organism, antibiotic that was ordered, if isolation was ordered, if the infection was a healthcare associated, a recultured date, and a date resolved. For each listed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-24 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, review of resident council minutes, review of facility policy, and resident and staff interview, the facility failed to prevent the resident's clothing from being lost when sent to laundry and failed to properly clean the resident's floor. This affected two (Residents #48 and #224) of three residents reviewed for clothing and a safe, clean, and comfortable environment. The facility census was 74. Findings include: 1. Review of the medical record revealed Resident #48 was admitted on [DATE]. Diagnoses included chronic respiratory failure, acute kidney disease, and atrial fibrillation. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 was cognitively intact. Interview on 10/21/24 at 9:48 A.M. with Resident #48 revealed a shirt and shorts were missing. Resident #48 stated he could not find the shirt or shorts in his room. Resident #48 stated missing laundry was brought up at resident council meetings a lot and it was still a problem.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-24 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, staff interview, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure admission and annual comprehensive Minimum Data Set (MDS) 3.0 assessments were completed timely and as required. This affected three (Residents #35, #39, and #171) of 36 residents reviewed for resident assessments. The facility census was 74. Findings include: 1. Review of Resident #35's medical record revealed an admission date of 10/24/19. Diagnoses included dementia, depression, and Parkinson's Disease. Review of Resident #35's annual MDS 3.0 assessment, dated 08/27/24 revealed the assessment was in progress (indicating incomplete and not yet submitted as required). Resident #35's prior annual MDS assessment was dated 08/30/23. An interview on 10/22/24 at 2:54 P.M. with MDS Coordinator #393 confirmed the comprehensive assessments for Resident #35 was not completed timely. 2. Review of Resident #39's medical record revealed an admission date of 08/10/23. Diagnoses included dementia, anxiety, and depression. Review of Resident #39's annual MDS 3.0…
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 before2024-09-04 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, staff interview, family interview, and policy review, the facility failed to accurately transcribe physician's orders for medications upon admission to the facility. This affected one (Resident #90) of three residents reviewed for admission procedures. The facility census was 76. Findings include: Review of the closed medical record for Resident #90 revealed an admission date of 08/02/24. Medical diagnoses included Alzheimer's disease, hyperlipidemia (elevated cholesterol), and hypertension (elevated blood pressure). Resident #90 was discharged from the facility on 08/12/24 with a family caretaker upon completion of his planned respite stay at the facility. Review of Resident #90's Minimum Data Set (MDS) 3.0 discharge return not anticipated assessment, dated 08/12/24, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 08, indicating moderately impaired cognition. Resident #90 was not recorded to have had any behaviors or rejection of care. Review of Resident #90's baseline care plan, dated 08/04/24, revealed the resident was not a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-04 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, staff interview, and policy review, the facility failed to ensure Resident #90 was free of significant medication errors. This affected one (Resident #90) of six residents reviewed for medication administration. The facility census was 76. Findings include: Review of the closed medical record for Resident #90 revealed an admission date of 08/02/24. Medical diagnoses included Alzheimer's disease, hyperlipidemia (elevated cholesterol), and hypertension (elevated blood pressure). Resident #90 was discharged from the facility on 08/12/24 with a family caretaker upon completion of his planned respite stay at the facility. Review of Resident #90's Minimum Data Set (MDS) 3.0 discharge return not anticipated assessment, dated 08/12/24, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 08, indicating moderately impaired cognition. Resident #90 was not recorded to have had any behaviors or rejection of care. Review of Resident #90's baseline care plan, dated 08/04/24, revealed the resident was not a candidate for self-administration of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-04 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, resident and staff interview, and policy review, the facility failed to label and store medications in a safe and secure manner. This affected one (Resident #55) and had the potential to affect 18 residents whom the facility identified as recipients of medications stored in Cart A on the 200-hallway. The facility census was 76. Findings include: 1. Review of the medical record for Resident #55 revealed an admission date of 08/08/24. Medical diagnoses included Review of Resident #55's Minimum Data Set (MDS) 3.0 admission assessment, dated 08/08/24, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Review of Resident #55's baseline care plan, dated 08/09/24, revealed the resident was not identified as a candidate to self-administer medications. Review of Resident #55's physician's orders revealed an order dated 08/08/24 for Sodium Chloride Nasal Solution 0.65%, administer 4 sprays in both nostrils three times daily for allergies. Resident #55 also had an order dated 08/08/24 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 · D2024-01-04 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on resident, family, and staff interviews and record review, the facility failed to provide the resident and the resident's representative in a timely manner for a daily room rate increase. This affected one resident (Resident #52) of three residents reviewed for billing practices. The facility census was 60. Findings include: Review of the medical record for Resident #52 revealed an admission date of 03/22/23. Medical diagnoses included metabolic encephalopathy, chronic respiratory with hypoxia, and diabetes mellitus. The resident was private pay status as of 06/10/23. The resident resided as the sole occupant in a semi-private room from 06/10/23 until 01/03/24 when he was moved to a private room. Resident #52 was listed as his own responsible party with his daughter, Family Member #200, was listed as his resident representative. Review of the facility's daily room rates and included services dated October 2023 revealed the facility semi-private room rate was $248 per day and the private room rate was $270 per day. Review of Resident #52's admission agreement revealed the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-09-26 · 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
Based on observations, record review, staff interviews, review of the Centers for Disease Control and Prevention (CDC) COVID-19 guidance, and policy review, the facility failed to ensure wore the proper Personal Protective Equipment (PPE) in resident rooms who were in isolation for COVID-19. This had the potential to affect 10 residents (#35, #60, #115, #120, #130, #135, #145, #150, #170, and #180) residents on the 100 B hall who had not tested positive for SARS-CoV-2 (COVID-19) in the facility outbreak dated 09/07/23. The facility census was 60. Findings include: Review of the facility's COVID-19 outbreak documentation dated 09/07/23 revealed the facility initiated COVID-19 outbreak status on 09/07/23. There were two residents (#100 and #100) currently in isolation for COVID-19 and resided on the 100 B-Hall unit. There were eight residents (#05, #40, #50, #55, #105, #124, #140 and #190) who had been infected with COVID-19 but had completed their isolation period, and 10 residents (#35, #60, #115, #120, #130, #135, #145, #150, #170 and #180) who had not been infected during 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 · D2022-07-13 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and staff interview, the facility failed to ensure the appropriate disciplines were notified per the plan of care, after a resident was observed in the dining room choking. This affected one (#37) of eight residents observed eating in the dining room. The census was 56. Findings include: Review of Resident #37's medical record revealed an admission date of 05/12/22, with diagnoses including metabolic encephalopathy, cerebral infarction, dementia, gastro-esophageal reflux disease. Review of physician orders dated 06/03/22 revealed speech therapist to treat Resident #37, five times per week for four weeks to address deficits and dysphagia, regular-sodium precautions diet, regular texture, and thin liquids consistency. Review of plan of care dated 06/08/22 revealed Resident #37 had a swallowing problem related to complaints of difficulty or pain with swallowing. Interventions included to monitor, document, and report to nurse, dietician, and physician for difficulty swallowing, holding food in mouth and prolonged swallowing time, coughing, throat…
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 · D2022-07-13 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, staff interviews, policy review and review of information from the National Pressure Injury Advisory Panel (NPIAP), the facility failed to accurately assess, and timely obtain a treatment when a resident was re-admitted to the facility with a pressure wound. This affected one (#40) of three reviewed for pressure ulcers. Facility census was 56. Findings include: Review of Resident #40's medical record revealed an admission date of 03/20/18 and readmission date of 07/01/22. Diagnoses for Resident #40 included atrial flutter, aphasia, kidney failure, and hemiplegia and hemiparesis. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #40 was cognitively intact. The resident required extensive assistance of two for bed mobility and transfer. Resident #40 had a Stage III (full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia) pressure ulcer. Review of the electronic facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-07-13 · 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 staff interview, the facility failed to ensure medical records were maintain with accurate documentation of a resident's condition. This affected two (#37 and #40) of 25 residents medical records reviewed. The census was 56. Findings include: 1. Review of Resident #37's medical record revealed an admission date of 05/12/22, with diagnoses including metabolic encephalopathy, cerebral infarction, dementia, gastro-esophageal reflux disease. Review of physician orders dated 06/03/22 revealed speech therapist to treat Resident #37, five times per week for four weeks to address deficits and dysphagia, regular-sodium precautions diet, regular texture, and thin liquids consistency. Observation on 07/05/22 at 11:32 P.M., with Stated Tested Nurses Aid (STNA) #506 revealed Resident #37 was eating his lunch in the dining room. Resident #37 was served a regular diet which included a cheeseburger. Observation revealed Resident #37 took a bite of the cheeseburger. Resident #37's face…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2024-10-24 · tag F0925 — failed to control pests — widespreadMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
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 food preparation and service areas were free from pests. This had to potential to affect all 74 residents residing in the facility. Findings include: Observation and interview on 10/21/24 at 9:57 A.M. with Dietary Supervisor (DS) #359 revealed five flies flying in the kitchen and landing on the ceiling and beverage line. DS #359 stated they have fly issue but the exterminator was here this morning and confirmed the five flies in the kitchen. Observation and interview on 10/22/24 at 10:04 A.M. with DS #359 revealed flies flying around the kitchen food preparation station and three flies on the ceiling. DS #359 confirmed the flies in the kitchen. Observation on 10/22/24 at 11:03 A.M. revealed three flies on the rack near the food steam table and three additional flies on the ceiling. Interview on 10/22/24 at 11:03 A.M. with Dietary [NAME] #344 confirmed the three flies near the steam table and three flies on the ceiling. Dietary [NAME] #344 revealed they have had a fly issue since the summer.…
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.
“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.
- 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 FOUNDATIONS HEALTH SOLUTIONS — 64 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 4.1 | -1.1 vs chain |
| Health inspection | 4 of 5 | 3.9 | +0.1 vs chain |
| Staffing | 1 of 5 | 2.3 | -1.3 vs chain |
| Quality measures | 3 of 5 | 4.3 | -1.3 vs chain |
The other 63 homes this chain runs (chain average 4.1★, per CMS)
Showing 40 of 63; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| COLLERAN, BRIAN | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/02/2024 |
| KRYSTOWSKI, JOHN | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/02/2024 |
| FOUNDATIONS HEALTH SOLUTIONS, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/02/2024 |
| HELLER, MEGAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/02/2024 |
| IDREES, GHULAM | Individual | ADP OF THE SNF | since 12/02/2024 |
CMS files one row per role, so the 11 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
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 $286K paid to related parties (affiliated landlords or management companies) in its most recent cost report. 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 366194. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-27, 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.