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Marion Nursing & Rehab

175 Community Drive, Marion, OH 43302 · For profit - Corporation · 99 certified beds · (740) 387-7537 Medicare & Medicaid certified

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Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Aug 2023Behavioral-health or dementia-care citation — no harm found (F0758)1 immediate-jeopardy citation$40,053 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

Worth asking about
  • 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
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $40,053 in federal fines (most recent 2023-12-18)
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (1/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1040 Delaware Ave · (740) 383-7950 · Call to confirm hours
Pharmacy
1040 Delaware Ave · (740) 383-4529 · Call to confirm hours
Grocery
1296 Delaware Ave · (740) 751-4003 · Call to confirm hours
Park
61-145 McKinley Park Blvd · (740) 387-5370 · Typically dawn to dusk
Place of worship
930 Harding Memorial Pkwy · (740) 382-4537

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 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.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased1.0%5.3%15.4%better than state — see note marked double-dagger below the table
Long-stay residents who lose too much weight3.8%6.2%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.2%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.4%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms90.5%30.1%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.0%3.2%3.3%better
Long-stay residents whose ability to walk worsened0.0%6.1%16.1%check this — see note marked star below the table
Long-stay residents on antianxiety or hypnotic medication32.2%25.5%18.9%worse
Long-stay residents given the seasonal flu vaccine87.5%94.5%95.3%typical
Long-stay residents with pressure ulcers0.4%3.4%4.7%better
Long-stay residents with worsening bladder/bowel control15.7%21.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table16.3%8.8%17.1%typical
Short-stay residents who newly got an antipsychotic medication3.4%1.2%1.4%worse
Short-stay residents given the seasonal flu vaccine31.0%75.6%79.4%worse
Short-stay residents rehospitalized after admission36.6%24.9%22.6%worse
Short-stay residents with an outpatient ER visit11.2%12.9%12.0%typical
Long-stay hospitalizations per 1,000 resident days1.761.731.67typical
Long-stay outpatient ER visits per 1,000 resident days2.361.801.80worse

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

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.

11.1%U.S. median 10.7%
Went back to hospital
not reportedno hours filed
Therapy hours / resident / day

Therapy staffing: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.

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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.1%CMS range 6.9–16.610.7%Oct 2022–Sep 2024no 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified81.8%98.7%Oct 2024–Sep 2025CMS 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 settingnot 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened4.5%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.831.02Oct 2022–Sep 2024CMS 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

0.54
RN hours/ resident / day
0.71
LPN hours/ resident / day
2.22
Aide hours/ resident / day
3.47
Total nurse hours/ resident / day
0.28
RN hoursweekends
39.4%
Total nursing turnover
0.0%
RN turnover

How full it usually is: this home is certified for 99 beds and averages 70.6 residents a day — about 71% occupied, or roughly 28 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.47 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.54 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.22 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.13 hrs/resident/day on weekends vs 3.61 on weekdays — 13% thinner on weekends. RN hours go from 0.65 to 0.28 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 39% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

7
deficiencies at the latest standard inspection (2026-02-23)
5
at the previous standard inspection (2023-08-24)

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.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

27 citations, most serious first. The 11 most serious are shown; the remaining 16 are one tap away and print in full.

  • Immediate jeopardy · Lcited before2023-12-18 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on Nursing Home Guidance from the Centers for Disease Control (CDC), medical record review, observation, interview with residents, interview with facility staff, and review of facility policy, the facility failed to appropriately implement the isolation procedures and use of Personal Protective Equipment (PPE) to prevent the spread of the SARS-CoV-2 virus (COVID-19) among facility residents. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, negative health outcomes, and/or death when the facility staff failed to require 13 residents (#19, #21, #42, #46, #47, #51, #55, #56, #59, #61, #62, #64, and #65) who were positive for COVID-19 to remain in isolation from the onset of the outbreak on 11/25/23. As of 12/12/23, 20 residents were identified as COVID-19 positive (Residents #02, #03, #05, #06, #07, #10, #19, #21, #31, #43, #45, #46, #47, #50, #51, #57, #58, #60, #61, and #62). These 20 residents are located throughout the facility since the facility does not have a dedicated COVID-19 unit. The facility also allowed six residents (#01, #04,…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-14 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and review of facility policy, the facility failed to ensure the bed hold included pricing information and also failed to provide a reason for transfer/discharge notices to the resident/representative and the Ombudsman. This affected three Residents (#77, #78, and #79) of three reviewed for discharge planning.Findings include:1. Review of the medical record for Resident #77 revealed an admission date of 03/22/26. Diagnoses included toxic effect of metals, diabetes, acute kidney failure, and muscle weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #77 was cognitively impaired and required staff assistance for activities of daily living. Review progress notes dated 03/17/26 revealed the resident was being transferred by staff and had seizure like activity. He was lowered to the ground and labs were obtained and identified a lithium toxicity level. The physician ordered intravenous (IV) fluids to be started and to recheck labs in six…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-02-23 · tag F0641 — pattern
    Ensure 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 observation, record review, review of the Minimum Data Set (MDS) Resident Assessment Instrument, review of facility policy, and interview, the facility failed to ensure all resident assessments were accurate and coded correctly in the MDS database. This affected six residents (#3, #21, #28, #44, #53, and #62) out of 24 residents reviewed for MDS assessments. The census was 67.Findings include:1.Record review for Resident #3 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #3 included congestive heart failure, chronic obstructive pulmonary disease, obesity, depression, diabetes type two, and anxiety. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed the resident had intact cognition, required two staff assistance with Activities of Daily Living (ADLs) and was receiving supplemental oxygen therapy, but was not coded for any type of mechanical ventilation. Review of the MDS quarterly assessment dated [DATE] revealed the resident was coded…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-23 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, interview, and review of facility policies, the facility failed to ensure a residents advanced directives status were addressed timely and accurate in the medical record. This affected one (Resident #59) out of 27 residents reviewed for advanced directives. The facility census was 67.Findings include: Review of the medical record for Resident #59 revealed an admission date of 08/22/25 with diagnoses including chronic obstructive pulmonary disease, emphysema, encephalopathy, malignant neoplasm, fibromyalgia and dementia.Review of Resident #59's physician orders dated 08/22/25 through 02/10/26 showed a Full Code status.Review of Resident #59's quarterly Minimum Data Set (MDS) 3.0 assessment completed on 11/12/25 showed the resident was cognitively intact.Review of Resident #59's care conference notes dated 12/04/25 showed the resident requested to change her code status from Full Code to Do Not Resuscitate Comfort Care (DNRCC).Review of Resident #59's signed DNRCC form dated 02/03/26 showed the resident elected DNRCC Arrest (A) which directs providers to treat…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-23 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to ensure a resident's splint noncompliance was recorded in their care plan. This affected one (Resident #57) out of 17 residents records reviewed for comprehensive care plans. The facility census was 67. Findings include:Review of the medical record for Resident #57 revealed an admission date of 02/08/19 with diagnoses of cerebral infarction, muscle weakness, cognitive communication deficit, reduced mobility, contracture of the right hand, hemiparesis and hemiplegia following cerebral infarction.Review of the care plan dated 11/14/25 revealed the resident had a need for a splint or brace program and was dependent on staff for application and removal. Interventions included assessing for pain, assessing for progress and need, explaining the procedure before performing it and applying a soft splint to the right hand to be worn daily as tolerated. The care plan noted no documentation regarding the residents refusal of the splint…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, review of hospital notes, review of facility timeline, interview, and review of facility policies and procedures, the facility failed to follow interventions to prevent a fall. This affected one resident (#3) out of three residents reviewed for falls. The facility also failed to ensure the safety and security of Resident #75 who was admitted to the memory care unit and was an elopement risk. This affected one resident (#75) of three reviewed for elopement. The facility census was 67.Findings include: 1. Record review for Resident #3 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #3 included congestive heart failure, chronic obstructive pulmonary disease, obesity, depression, diabetes type two, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition, required two person assistance with Activities of Daily Living (ADLs) and was a fall risk. Review of Resident #3's care…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-23 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide 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 interview, record review, and review of facility policy, the facility failed to ensure weight measurements were verified after a significant weight change. This affected one (Resident #22) out of four residents reviewed for weight loss. The facility census was 67. Findings include:Review of the medical record for Resident #22 revealed an admission date of 10/06/23 with diagnoses including acute and chronic respiratory failure, chronic obstructive pulmonary disease (COPD), morbid obesity, hypertensive heart disease with heart failure, acute pulmonary edema, peripheral vascular disease and shortness of breath.Review of the care plan dated 12/17/24 revealed the resident was at risk for altered nutritional and hydration status with interventions to administer medications as ordered, monitor for malnutrition, obtain laboratory (lab) and diagnostic work as ordered, provide prescribed diet and have the dietitian evaluate and make recommendations.Review of the annual Minimum Data Set 3.0 assessment completed…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-23 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    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 supplemental oxygen was administered per physician order. This affected one (Resident #22) out of five residents identified as receiving oxygen administration. The facility census was 67.Findings include:Review of the medical record for Resident #22 revealed an admission date of 10/06/23 with diagnoses including acute and chronic respiratory failure, chronic obstructive pulmonary disease (COPD), morbid obesity, hypertensive heart disease with heart failure, acute pulmonary edema, peripheral vascular disease and shortness of breath. Review of the annual Minimum Data Set 3.0 assessment completed 12/18/25 revealed the resident was cognitively intact and was receiving oxygen therapy. Review of the physician order dated 12/31/25 revealed the resident was ordered oxygen at 3 liters per minute by nasal cannula continuous inhalation. Review of care plan dated 02/03/26 revealed the resident had oxygen therapy related to COPD. Interventions included to give medications as ordered 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-23 · tag F0770 — failed to provide lab services — isolated
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    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 execute timely laboratory orders. This affected one resident (Resident #48) of two residents reviewed for laboratory services. The facility census was 67.Findings include:Review of the medical record for Resident #48 revealed the resident was admitted on [DATE] and had diagnoses including Huntington's disease, overactive bladder, and spinal stenosis of the lumbar region.Review of Resident #48's quarterly Minimum Data Set (MDS) 3.0 assessment submitted 01/22/26 revealed the resident had severe cognitive impairment.Review of Resident #48's progress notes written by Licensed Practical Nurse (LPN) #239 on 12/19/25 at 6:04 P.M. stated that Resident #48 was engaging in unusual behaviors. Examples included cleaning walls with tissue paper and attempting to put lotion on a sandwich. The progress note stated LPN #239 contacted Certified Nurse Practitioner (CNP) #616 and orders were received to check for a urinary tract infection (UTI).Review of Resident #48's…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-04-21 · tag F0921 — failed to keep a safe, functional, sanitary building — widespread
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and review of a job description, the facility failed to ensure the doorbell to the front entrance of the facility was functional. This had the potential to affect all 77 residents residing in the facility. The facility census was 77. Findings include: Observation on 04/21/25 at 8:32 A.M. revealed the doorbell to the front door of the facility was missing a cover plate. The button on the doorbell was pushed twice and the doorbell would not ring and made no sound. There was no sign posted with the facility telephone number to obtain assistance to enter the building. Interview on 04/21/25 at 8:52 A.M., the Administrator revealed on 04/16/25 a nurse notified her the facility telephones and internet were not working and were out for a few hours until fixed. The Administrator revealed she was unaware if the doorbell to the facility was functioning. The Administrator revealed she had been at the facility for about six months and never checked to see if the doorbell was functioning. Observation and interview on 04/21/25 at 9:02 A.M. with 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-04-21 · tag F0919 — failed to provide a working call system — pattern
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, review of a job description, and policy review, the facility failed to ensure the call light system was functioning for all residents and timely repairs were made to the system. This affected 23 of 77 facility residents including nine (#1, #11, #16, #28, #40, #50, #55, #62, and #71) residents with no functioning call light and an additional 14 (#18, #22, #26, #34, #37, #47, #53, #56, #58, #60, #63, #70, #75, and #76) residents with intermittent functioning call lights. The facility census was 77. Findings include: Interview on 04/21/25 at 8:52 A.M., with the Administrator revealed there were a few rooms on the north end of the facility where the call lights were not working and would have to check how long they had not been working. The Administrator revealed the residents were given hand bells and revealed she had gotten a couple of quotes for repair and replacement of the call light system. The Administrator revealed the staff had increased the frequency 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
Show the remaining 16 citations
  • Potential for harm · F2024-09-26 · tag F0908 — failed to keep essential equipment working — widespread
    Keep all essential equipment working 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, staff interview, and review of policy, the facility failed to ensure the crash carts (emergency use) were stocked with non-expired medical devices. This had the potential to affect all 69 residents residing in the facility. The census was 69. Findings include: Observation, along with Licensed Practical Nurse (LPN) #171, on [DATE] at 9:30 A.M., revealed the crash cart(located in the nurses station on the skilled nursing side) contained four 10 milliliter syringes with expiration date of [DATE]. The cart contained three 22 gauge angiocaths with expiration date of [DATE], two 20 gauge angiocaths with expiration date of [DATE], five intravenous start kits with expiration dates of (3) [DATE] and (2) [DATE], and an unopened, sealed bottle of blood glucose test strips dated [DATE]. The cart in the locked dementia unit contained three suction catheter kits dated [DATE] and a sealed providone swab stick expired 10/23. Interview at the time of the observation, with LPN #171 verified all of the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-09-26 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and review of the policy, the facility failed to ensure the glucose monitor device was cleaned after use. This directly affected three residents (#26, #67 and #68) and had the potential to affect 15 residents (#16, #18, #21, #23, #32, #36, #37, #39, #44, #48, #50, #52, #56, #61, and #63), identified by the facility as having blood glucose monitored using the blood glucose device. The facility census was 69. Findings include: Observation on 09/27/24 at 5:35 A.M., revealed Licensed Practical Nurse (LPN) #100 used a blood glucose monitor device to obtain a blood glucose result on Resident #26. After obtaining the result, LPN #100 used an alcohol swab to cleanse the monitor device. Interview directly following, with LPN #100 provided verification the alcohol swab was not the correct substance to clean the device. Observation on 09/27/24 at 5:53 A.M., revealed LPN #103 to obtain a blood glucose reading using a blood glucose device for Resident #67. LPN #103 did not clean the device before proceeding to use the device to obtain a blood glucose result…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-26 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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 medical record review, staff interview, and policy review, the facility failed to properly assess and treat a resident's rash. This affected one (#1) out of three residents reviewed for a change in condition. The facility census was 69. Findings include: Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included dementia, anxiety, depression, hypertension, muscle weakness, and need for assistance with personal care. Review of the admission Minimum Data Set assessment, dated 07/19/24, revealed Resident #1 was identified as cognitively impaired. The resident required assistance from staff for all activities of daily living. Review of Resident #1's medical record for 09/06/24 and 09/07/24 revealed no other information, documentation, or assessment regarding a rash. Review of the shower sheet dated 09/07/24, revealed Resident #1 had a rash on their left thigh. Review of the nursing progress notes dated 09/08/24 and timed 10:00 A.M., revealed the nurse 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-04-02 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and policy review, the facility failed to ensure food was served at safe holding food temperatures. The deficient practice had the potential to affect all 63 residents that receive food from the kitchen. The facility census was 63. Findings include: Observation on 04/02/24 at 12:19 P.M., with Dietary Manager #35 and District Manager #95, of the tray line revealed the lunch menu consisted of meatballs, capris vegetables, and white rice. Dietary Manager #35 gave a thermometer and santizer wipes to [NAME] #40. [NAME] #40 then temperature tested the food on tray line being served on the test tray. The meatballs were 150 degrees Fahrenheit, the capris vegetables were 127 degrees Fahrenheit, and the white rice was 130 degrees Fahrenheit coming out of hot holding to be placed on the test tray. The test tray left the kitchen at 12:21 P.M. Observation of tray distribution in the Reflections unit started on 04/02/25 at 12:24 P.M. Interview on 04/02/24 at 12:26 P.M., with Dietary Manager #35 revealed she was not aware what temperature the food should be…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-12-18 · tag F0580 — failed to tell family and doctor about changes — pattern
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility staff interview, and policy review, the facility failed to notify the responsible party for two residents (#21 and #57) of four reviewed for COVID-19 that they were positive for SARS-CoV-2 virus (COVID-19), and the facility failed to notify the responsible party of six (#01, #04, #08, #20, #32, and # 63) of six residents reviewed who were COVID-19 negative that the resident remained in a room with a COVID-19 positive roommate. The total facility census was 64. Findings include: 1. Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including obstructive hydrocephalus, bradycardia, dementia, epilepsy, chronic obstructive pulmonary disease, bipolar disorder, and depression. Resident #21 was documented to have a guardian over her care at the facility. Review of the state optional minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had mild cognitive impairment, no behaviors, required extensive…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-12-18 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide 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 and facility staff interview, the facility failed to monitor six (#01, #04, #08, #20, #32, and #63) of six residents who were COVID-19 negative and remained in a room with a COVID-19 positive roommate for signs and symptoms of COVID-19. The total facility census was 64. Findings include: 1. Review of Resident #01's medical record revealed the resident was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, paranoid schizophrenia, weakness, hypertension and cardiac murmur. Resident #01's medical record lacked evidence that the resident was having her temperature taken daily or was being observed daily for signs and symptoms of COVID-19. Review of the facility's COVID -19 tracking revealed Resident #01 was negative for COVID-19, but remained in a room with a COVID-19 positive roommate. 2. Review of Resident #04's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, anxiety, pneumonia, dysphagia,…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-18 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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, facility staff interview, and policy review, the facility failed to update care plans for three (#21, #57 and #61) of four residents reviewed for being COVID-19 positive. The total facility census was 64. Findings include: 1. Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including obstructive hydrocephalus, bradycardia, dementia, epilepsy, chronic obstructive pulmonary disease, bipolar disorder, and depression. Review of the 10/12/23 state optional Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had mild cognitive impairment, no behaviors, required extensive assist from one for bed mobility, transfers, toileting and supervision for eating. The resident had order for isolation and observation due to positive COVID status for 10 days dated 12/04/23. Care plans reviewed revealed the resident is long term care at the facility. That she likes to spend most of her time outside her room in communal…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-08-24 · tag F0921 — failed to keep a safe, functional, sanitary building — widespread
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff and resident interviews, the facility failed to ensure a safe environment for residents, staff, and visitors. This had the potential to affect all 62 residents residing in the facility. Findings include: The initial tour was conducted on 08/21/23 from 8:30 A. M. to 9:00 A.M. and revealed the entry way into the facility contained two glass doors. The first entry door (from the outside, door number one) from the bottom of the glass door closest to the floor extending up three quarters of the door and the entire width of the door, the glass was shattered. It appeared to have a shattered circle of glass in the center of the door with extending cracked glass to forming sharp lines of cracked glass extending in every direction. The area resembled a sun beam design or a spider web effect. Four feet in front of the first entry glass door was another glass door into the lobby of the facility. Door number two was shattered at the bottom right side about 24 inches wide and extended up to the middle of the door, the shattered glass was covered with a two-inch tape…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-24 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident and staff interview, review of the facility's self-reported incidents (SRIs), and review of the facility policy, the facility failed to timely report an allegation of physical abuse of a resident to the State Survey Agency. This affected one (Resident #66) of two residents reviewed for abuse. The facility census was 62. Findings include: Review of the medical record for Resident #66 revealed an admission date of 01/26/23. Diagnoses included chronic obstruction pulmonary disease, schizophrenia, depressive disorder, pain in shoulder, cognitive communication deficit, psychotic disorder, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 was cognitively intact and required limited to extensive assistance of one staff member for mobility and transfers. Interview on 08/22/23 at 9:00 A.M. with Resident #66 revealed she had an allegation of abuse with State Tested Nursing Aide (STNA) #126 smacking her during care. Resident #66 revealed…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-24 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, review of the facility policy, and record review, the facility failed to ensure the resident's pre-admission screening and resident interview (PASARR) assessment was completed accurately to include all the resident's mental health diagnoses. This affected one (Resident #66) of two residents reviewed for PASARR assessments. The facility census was 62. Findings include: Review of the medical record for Resident #66 revealed an admission date of 01/26/23. Diagnoses included schizophrenia and psychotic disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 was cognitively intact. Review of the PASARR assessment dated [DATE] revealed Resident #66 was marked to have a diagnosis of schizophrenia. Psychotic disorder was not marked as a diagnosis for Resident #66. Interview on 08/22/23 at 2:25 P.M. with Social Services Designee (SSD) #121 revealed she completed the resident's PASARR assessments. SSD #123 denied having knowledge of a diagnosis not matching…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-24 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, review of the facility policy, and record review, the facility failed to ensure a resident receiving an as needed psychotropic medication had an end date and/or was re-evaluated by the medical provider every 14 days. This affected one (Resident #66) of five residents reviewed for unnecessary medication. The facility census was 62. Findings include: Review of the medical record for Resident #66 revealed an admission date of 01/26/23. Diagnoses included schizophrenia, psychotic disorder, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 was cognitively intact. Review of Psychiatric Practitioner notes dated 06/29/23 revealed Resident #66 was having anxiety and a new medication would be started, Vistaril 25 milligrams (mg) as needed (PRN) every six hours for anxiety. Review of Resident #66's physician orders dated 06/29/23 revealed an order for Vistaril (Hydroxyzine Pamoate) 25 mg capsule with instructions to administer one capsule by mouth…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-24 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard 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 staff interviews and medical record reviews, the facility failed to ensure the resident's medical record was accurate. This affected two (Residents #11 and #34) of 19 residents reviewed for medical record accuracy. The facility census was 62. Findings include: 1. Review of the medical record for Resident #34 revealed an admission date of 05/04/18. Diagnoses included Alzheimer's disease, anemia, and dementia. Review of the Resident #34's nursing progress notes dated 01/17/23 and 02/05/23 revealed she was being treated for some kind of rash. Review of Resident #34's care conference documentation dated 03/22/23 revealed Resident #34 continued to have a rash on her entire body. Review of the state tested nursing aide (STNA) shower sheets dated from 01/02/23 to 06/29/23 revealed Resident #34 had a rash on her body during a six-month time frame. Review of Resident #34's Hand-Skin Observation sheets completed weekly from 01/3/23 to 07/23/23 revealed the weekly observation sheets were completed inaccurately as…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2021-06-24 · tag F0730 — widespread
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to conduct 90-day and annual performance evaluations for two State Tested Nursing Assistants (STNA #614 and #713). This had the potential to affect all resident in the facility. Facility census 83. Findings include: 1. Review of the personnel records for State Tested Nursing Assistant (STNA) #614 revealed a hire date of 07/17/19. Review of the performance evaluation history revealed the last performance evaluation was completed on 10/31/19. No annual evaluation was present in the employee's file. 2. Review of the personnel records for STNA #713 revealed a hire date of 07/16/20. Review of the performance evaluation history revealed the 90-day performance evaluation was not present in the employee's file. During interview on 06/23/21 at 4:35 P.M., Administrative Assistant #502 revealed the personnel records were lacking the above information.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2021-06-24 · tag F0805 — failed to prepare food in a form residents can eat — pattern
    Ensure 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 record review, observation and interview, the facility failed to serve appropriately pureed potato salad to four (Residents #7,#5, #90 and #29) of five residents reviewed for puree consistency. The facility identified five residents who were ordered pureed meals. Findings include: Review of a facility provided list dated 06/24/21 revealed Resident #7, Resident #5, Resident #90, and Resident #29 were prescribed pureed meals and served pureed potato salad for the lunch meal 06/23/21. 1. Review of Resident #7's medical record revealed she admitted to the facility 03/22/21. Diagnoses included Alzheimer's disease. Review of a physician order dated 03/31/21 revealed she was ordered a regular, pureed diet. 2. Review of Resident #5's medical record revealed she admitted to the facility 03/15/21. Diagnoses included Chronic obstructive pulmonary disease. Review of a physician order dated 04/06/21 revealed she was ordered a regular, pureed diet. 3. Review of Resident #90's medical record revealed she admitted to the facility 01/14/21. Diagnoses included cerebral infarction. Review of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2021-06-24 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and policy review, the facility failed to maintain sanitary conditions during meal preparation. This affected all residents who ate from the kitchen except Resident #71, Resident #63, and Resident #12. Findings include: 1. Observation and subsequent interview on 06/21/21 at 10:30 A.M. with Dietician #600 revealed there were conglomerated strings and clumps of dust hanging from the light covers over the entire meal preparation area that was easily visible. Dietician #600 confirmed the presence of the dust build-up on the lighting fixtures over the meal preparation area. 2. Observation and subsequent interview on 06/23/21 at 10:38 A.M. with Dietary Staff #313 revealed during the process of pureeing resident meals, he doffed his gloves, removed the lid of the refuse can, disposed of trash, and took soiled utensils to the three-compartment sink. Dietary Staff #313 then placed both soiled hands on the open, top rim of the thickener powder contained, and moved the container eight inches down the preparation table. Dietary Staff #313 confirmed his hands 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-06-24 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide 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 and interview, the facility failed to provide fluids to a resident in a specialized cup. This affected one (Resident #70) of four residents reviewed for appropriate assistive devices. The facility identified 12 residents who required assistive devices with meals. Findings include: Review of Resident #70's medical record revealed she admitted [DATE]. Diagnoses included Alzheimer's disease. Review of a physician order dated 03/31/21 revealed Resident #70 was prescribed a regular, mechanical soft diet. Review of Resident #70's care plan dated 02/16/21 revealed she was at risk for altered nutritional status related to Alzheimer's disease. Interventions included a handled cup with a spout lid. During observation on 06/21/21 at 11:42 A.M., Resident #70 had one regular cup and one handled cup with a spout lid, each filled with a different beverage. Resident #70 attempted to pick up her regular fluid-filled cup and inadvertently spilled it on the dining room table. During interview on 06/21/21 at…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$40,053 in federal fines across 1 penalty.

  • $40,053 — penalty dated 2023-12-18

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.

Who owns this facility

Owner / managerTypeRoleSince
Ownership Data Not Available

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

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.

$6.4M
Net patient revenuemost recent cost report
-5.9%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 69%Medicare 2%Other / private 29%

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

$279per resident / day
operating cost
$8,470per month
≈ monthly operating cost
$263per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in Ohio
$9,186/mo
Nursing home (semi-private)
$10,389/mo
Nursing home (private)
$6,103/mo
Assisted living

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 365329. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-23, 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.

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