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Meadow Wind Health Care Center

300 23rd Street NE, Massillon, OH 44646 · For profit - Limited Liability company · 99 certified beds · (330) 833-2026 Medicare & Medicaid certified

Call the home — (330) 833-2026 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Resident-funds citation (F0567)Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
Worth asking about
  • it has a citation for mishandling residents’ money or property (F0567)
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (2/5)

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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2800 Lincoln Way E · (330) 837-0220 · Call to confirm hours
Pharmacy
Pharmacy0.2 mi
2032 Lincoln Way East
Grocery
2216 Lincoln Way E · (330) 497-3000 · Call to confirm hours
Park
54 Pine St SE · (330) 832-1621 · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 3 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 4 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating4★
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 increased10.2%5.3%15.4%worse than state — see note marked double-dagger below the table
Long-stay residents who lose too much weight6.3%6.2%5.4%worse
Long-stay residents with a catheter left in their bladder0.8%0.2%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.8%0.4%2.0%worse than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms2.8%30.1%6.5%better 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 injury3.3%3.2%3.3%typical
Long-stay residents whose ability to walk worsened9.2%6.1%16.1%worse than state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication37.1%25.5%18.9%worse
Long-stay residents given the seasonal flu vaccine96.9%94.5%95.3%typical
Long-stay residents with pressure ulcers9.1%3.4%4.7%worse
Long-stay residents with worsening bladder/bowel control19.5%21.4%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table1.3%8.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.4%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine64.1%75.6%79.4%worse
Short-stay residents rehospitalized after admission27.3%24.9%22.6%worse
Short-stay residents with an outpatient ER visit8.6%12.9%12.0%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.

48.1% 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 69 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

48.1%U.S. median 51.5%
Got home and stayed home
10.2%U.S. median 10.7%
Went back to hospital
54.3%U.S. median 56.6%
Met the expected recovery
0.38U.S. median 0.31
Therapy hours / resident / day
0.17hours / resident / day
Physical therapy
0.14hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 54.3% 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 35 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 0.38 therapist hours per resident per day in 2026Q1 — more than 65% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 23% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF48.1%CMS range 37.6–61.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.2%CMS range 6.6–15.010.7%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 discharge54.3%56.6%Oct 2024–Sep 2025CMS 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 discharge45.7%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge34.3%50.0%Oct 2024–Sep 2025CMS 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 identified98.0%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 discharge100.0%98.7%Oct 2024–Sep 2025CMS 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 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 worsened0.0%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 hospitalization6.4%CMS range 3.6–10.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.961.02Oct 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

0.69
RN hours/ resident / day
0.72
LPN hours/ resident / day
2.49
Aide hours/ resident / day
3.90
Total nurse hours/ resident / day
0.35
RN hoursweekends
56.0%
Total nursing turnover
46.2%
RN turnover

How full it usually is: this home is certified for 99 beds and averages 79.2 residents a day — about 80% occupied, or roughly 20 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 3.90 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.69 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.49 is at or above 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 3.24 hrs/resident/day on weekends vs 4.17 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 0.83 to 0.35 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 56% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

5
deficiencies at the latest standard inspection (2024-10-10)
6
at the previous standard inspection (2022-06-29)

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.

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.

25 citations, most serious first. The 11 most serious are shown; the remaining 14 are one tap away and print in full.

  • Actual harm · Gcited before2026-07-01 · 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 record review, staff and resident interview, and review of facility policy, the facility failed to ensure Resident #44 received treatment and care in accordance with professional standards of practice for treatment of urinary tract infection.Actual harm occurred to Resident #44 on 06/07/26, when the facility failed to notify the nurse practitioner (NP) of abnormal urine analysis and culture results, which were positive for Klebsiella pneumoniae ESBL (extended spectrum beta-lactamase) bacteria greater than 100,000 colony-forming units per milliliter, causing a delay in treatment for a urinary tract infection (UTI). The results were not reported to the NP until 06/16/26 at approximately 9:51 P.M. At approximately 11:00 P.M. on 06/16/26, Resident #44 was found by Licensed Practical Nurse (LPN) #515 during medication pass to slowly respond to questions but not open her eyes and had an abnormal pulse of 44 beats per minute. At 12:35 A.M. on 06/17/26 Resident #44 was transported by emergency medical services…

    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 · D2026-07-01 · tag F0641 — isolated
    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 record review and interview, the facility failed to ensure the accuracy of resident assessments. This affected two residents (Resident #9 and Resident #11) reviewed for accuracy of assessments. The facility census was 77. Findings include:1.Review of the medical record for Resident #9 revealed an admission date of 04/24/26. Diagnoses included acute respiratory failure with hypercapnia; acute bronchitis due to other specified organisms; dependence of respirator (ventilator); pseudomonas; muscle weakness, dysphagia; symbolic dysfunctions; weakness; need for assistance with personal care; pneumonia; acute and chronic respiratory failure with hypoxia; chronic obstructive pulmonary disease with exacerbation; benign prostatic hyperplasia with lower urinary tract symptoms; type two diabetes mellitus without complications. Review of medication orders, both current and discontinued, revealed no orders for insulin injections. Review of medication orders revealed on 05/23/26, Resident #9 was ordered Levaquin…

    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 · D2026-07-01 · tag F0678 — failed to provide CPR when needed — isolated
    Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the facility investigation, staff and family interviews and review of facility policy, the facility failed to ensure advance directives were honored for residents. This affected one (Resident #91) of two residents reviewed for Cardio-pulmonary Resuscitation (CPR). The facility also failed to ensure advanced directives were accurate in the medical records. This affected one (Resident #28) of 29 residents reviewed for advance directives. The facility census was 77.Findings include: 1.Review of the closed medical record for Resident #91 revealed an admission date of [DATE] with diagnoses of acute respiratory failure with hypoxia, and pulmonary embolism and tracheostomy status. Resident #91 did not have a power of attorney or legal guardian. Resident #91's son was listed as the first emergency contact, and daughter-in-law was listed as the second emergency contact. Review of the physician order dated [DATE] for Resident #91 revealed the resident had a Do Not Resuscitate Comfort 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 · D2026-07-01 · tag F0685 — isolated
    Assist a resident in gaining access to vision and hearing services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and staff interviews, the facility failed to ensure vision services were provided to Resident #90. The affected one (Resident #90) of one resident reviewed for vision services. The facility census was 77.Findings include: Review of the medical record for Resident #90 revealed admission date of 03/02/26 for diagnoses of end-stage renal disease, renal dialysis, heart failure, dysphagia, and a dialysis fistula. Review of the facility admission packet for Resident #90 revealed a consent signed by Resident #90's daughter and dated 03/02/26 to receive services from 360 Care (ancillary service partner) for audiology, vision, and podiatry services.Review of the initial comprehensive MDS 3.0 assessment completed on 03/09/26 for Resident #90 revealed she required hearing aid and use of glasses with no significant impairments and able to make self-understood and understood others. Resident #90 required substantial to maximum assistance with oral hygiene, toileting, dressing, and transfers and partial to moderate assistance with showering/bathing.Review of physician…

    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 before2026-07-01 · 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 record review, interview and review of facility policy the facility failed to inform the nurse practitioner of a dietary recommendation to address hydration needs for Resident #96. This affected one resident (Resident #96) of four residents reviewed for change of condition. The facility census was 77.Findings include:Review of the closed medical record for Resident #96 revealed an admission date of 10/01/24 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, chronic systolic congestive heart failure, need for assistance with personal care, muscle weakness, hypothyroidism, mild gastritis and gastrointestinal bleed. Resident #96 was discharged to the hospital on [DATE] and did not return to the facility.Review of the care plan for Resident #96, initiated 10/05/24 and revised on 05/21/26, revealed she was at risk for altered nutrition and fluid imbalance related to hypothyroid, gastrointestinal bleed, stroke, mild gastritis, congestive heart…

    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 · D2026-07-01 · 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 and record review, the facility failed to ensure respiratory equipment was maintained in a sanitary manner. This affected three (Residents #35, #67 and #70) of four residents reviewed for respiratory care. The facility census was 77. Findings include:1. Review of the medical record for Resident #35 revealed an admission date of 09/14/23 with diagnoses including chronic respiratory failure, tracheostomy status, and dependence on respiratory ventilator status. Review of the physician's orders revealed Resident #35 was to have his oxygen tubing and set-up changed every Thursday and as needed dated 11/03/25. Review of the Treatment Administration Record (TAR) for June 2026 revealed Resident #35's oxygen tubing was to be changed on 06/18/26 and staff had not completed this as ordered. Observation and interview on 06/22/26 at 10:18 A.M. of Resident #35 with Respiratory Therapist (RT) #535 revealed his oxygen tubing was dated 06/12/26. RT #535 verified his oxygen tubing should have been changed on 06/18/26. She verified the respiratory department was in…

    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 · D2026-07-01 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and review of the facility assessment, the facility did not ensure licensed nursing staff completed competencies on hire and demonstrated competencies and skill sets necessary to provide care and services based on residents assessed needs. This affected two (Resident #44 and #96) of two residents reviewed for competent nursing services. The facility census was 77.Findings include:1.Review of the medical record for Resident #44 revealed an admission date of 02/07/25. Diagnoses included atherosclerotic heart disease of native coronary artery without angina pectoris, noninfective gastroenteritis and colitis, muscle weakness, pressure ulcer of sacral region, stage three, peptic ulcer, moderate protein-calorie malnutrition, bradycardia, hypotension, and intestinal bypass and anastomosis status. Review of the medical record for Resident #44 revealed on 06/03/26, Resident #44 had a urinalysis completed with culture and sensitivity that was positive for urinary infection. The result 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-07-01 · tag F0880 — failed to prevent and control infections — isolated
    Provide 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, interview, record review and review of facility policy, the facility failed to ensure staff followed proper infection control procedures during incontinence care for Resident #55. The affected one resident (#55) of three residents reviewed for incontinence care. The facility census was 77.Findings include: Review of the medical record for Resident #55 revealed admission to the facility on [DATE] with diagnoses including hemiplegia of right side, dementia and bowel and urine incontinence.Review of the minimum data set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #55 was not able to vocalize her care needs and unable to complete the brief interview for mental status. Further review of the MDS revealed Resident #55 was dependent on staff for all personal care including showering/bathing, dressing, mobility with a wheelchair, and transfers with a mechanical lift. Resident #55 required a feeding tube for nutrition.Observation on 06/23/26 at 1:30 P.M. of incontinence 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-10-10 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, policy review, medical record review and interview, the facility failed to implement isolation protocols and failed to maintain infection control during tracheostomy care and blood glucose monitoring. This had the potential to affect all 75 residents in the facility. Findings include: 1. Review of Resident #178's medical record revealed diagnoses including history of malignant neoplasm of the breast and intestine and dyspnea. On 09/28/24, Resident #178 tested positive for COVID-19 and was placed in droplet isolation. The isolation was to be discontinued 10/09/24. On 10/07/24 at 12:47 P.M., Certified Occupational Therapy Assistant (COTA) #820 was observed opening Resident #178's door to exit into the corridor. The N95 mask she was wearing in Resident #178's room remained on. After opening the door, COTA #820 removed the N95. Without performing hand hygiene, COTA #820 reached around the door and into the isolation cart to obtain a new N95 mask and held it over her face. COTA #820 pushed 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-10 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview the facility failed to cover an indwelling urinary catheter drainage bag. This affected one resident (Resident #276) out of two residents reviewed for indwelling urinary catheters. The facility census was 75. Findings Include: Review of the medical record for Resident #276 revealed an admission date 10/03/24 with diagnoses including history of falls, history of urinary tract infection (UTI), chronic kidney disease, and type two diabetes mellitus. Resident #276 required assistance from staff for activities of daily living (ADL) tasks, used a front wheeled walker for ambulation assistance, and was receiving physical and occupational therapy services. Review of Resident #276 physician orders revealed an order dated 10/03/24 for foley catheter bag cover every shift, an order dated 10/04/24 for privacy cover to foley catheter drainage bag every shift for maintaining dignity, and an order dated 10/03/24 for foley catheter care every shift. Review of Resident #276 baseline care plan dated 10/03/24 revealed Resident #276 was admitted with…

    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 · D2024-10-10 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview and facility policy review, the facility failed to ensure enteral tube feeding bottles and water flush bags were properly labeled with the flow rate and the date and time the bottles/bags were hung for administration for Resident #176, and failed to ensure orders were obtained for Resident #177 regarding cleaning and flushing of an enteral feeding tube. This affected two residents (Resident #176 and #177) out of two residents reviewed for enteral tube feedings. The facility census was 75. Findings Include: 1. Review of the medical record for Resident #176 revealed an admission date 05/10/24 with diagnoses including chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), depression, anxiety, heart failure, and placement of a percutaneous endoscopic gastrostomy (PEG) tube. Resident #176 was cognitively intact and required assistance from the staff for activities of daily living (ADL) tasks including medication administration and tube…

    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
Show the remaining 14 citations
  • Potential for harm · D2024-10-10 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure parameters were in place for the administration of pain medications. This affected one resident (Resident #2) of five reviewed for unnecessary medications. The facility census was 75. Findings include: Review of the medical record for Resident #2 revealed an admission date of 07/11/24. Diagnoses included respiratory failure, cerebral palsy, depression, tracheostomy and scoliosis. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #2 was severely cognitively impaired. She was totally dependent for oral and personal hygiene, toileting, dressing and showering. She received hospice services. Review of the physician's orders for October 2024 revealed an order for Acetaminophen 500 milligrams (mg) 1 tablet via peg tube every eight hours as needed for pain which began on 07/25/24 and an order for Morphine 0.5 milliliters (ml) every two hours as needed for pain which began on 08/26/24. Review of the 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-01 · 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 record review, interview, and facility policy review the facility failed to accurately assess, document, and treat a new onset of a diabetic ulcer for Resident #80, who was dependent on staff for care. This affected one resident (#80) out of three residents reviewed for skin impairment. The facility census was 79. Findings include: Review of the medical record for Resident #80 revealed an admission date of 07/10/23 with a discharge to the hospital on [DATE]. Diagnoses included type two diabetes mellitus, Alzheimer's disease, high blood pressure, and chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #80 had impaired cognition. Resident #80 was dependent for bed mobility, transfers, and was non-ambulatory. Review of Resident #80's behaviors revealed the resident would be combative and aggressive when receiving care from staff. Resident #80 was receiving dressing changes to the right foot. Review of the plan of care dated 07/10/23 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-18 · 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 record reviews and interviews, the facility failed to implement nutritional interventions to monitor Resident #101's weights and thoroughly address weight loss timely. This affected one resident (Resident #101) of three residents reviewed. The census was 81. Findings include: Review of the closed medical record for Resident #101 revealed an admission date of 08/01/23. Resident #101 passed away at the facility on 10/25/23. Resident #101's diagnoses included low body mass index, chronic obstructive pulmonary disease, hypertension, ataxic gait and major depression. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #101 was cognitively intact. No weight loss was noted on the assessment and he required supervision for eating. Review of the progress notes revealed a Nutritional assessment dated [DATE] was completed by the Registered Dietitian (RD) #207. The assessment indicated Resident #101 would receive a regular diet, thin liquids, health shakes with all meals, and had a current…

    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 · F2022-06-29 · 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 — the official record, unedited, may be distressing

    Based on observation and interview the facility failed to maintain the outside courtyard area (designated smoking area) in a clean and sanitary condition. This had the potential to affect all residents. The facility census was 70. Findings include: On 06/27/22 at 12:51 P.M., observation of the courtyard/designated smoking area revealed more than 20 cigarette butts on the ground, in the combustible trash can, and combustible trash in the cigarette butts only metal can. Interview with the Maintenance Director #664 verified this finding at the time of observation.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-06-29 · tag F0567 — failed to protect residents' money held by the home — isolated
    Honor the resident's right to manage his or her financial affairs.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and staff interview the facility failed to ensure authorization from a resident or a sponsor with a power of attorney for management of personal funds was attested to by a witness not connected to the facility. This affected one (Residents #22) of five (Resident's #11, #21, #22, #36 and #40) whose personal fund accounts were reviewed. The facility census was 70. Findings include: Review of the authorization to manage funds for Resident #22 revealed no non-facility affiliated witness signature was obtained as required. 06/28/22 at 2:12 P.M. Administrator verified lack of witness signatures for Resident #22.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-06-29 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to ensure the Ombudsman's office was notified of resident transfers to the hospital as required. This affected one (Resident #263) of one resident reviewed for hospitalization. This had the potential to affect all residents. The facility census was 70. Findings include: Review of the medical record revealed Resident #263 was admitted to the facility on [DATE] with diagnoses including dysphagia, lack of coordination, and muscle weakness. Review of the medical record for Resident #263 was sent to the hospital on [DATE] and was subsequently admitted to the hospital. Review of both the electronic and hard charts revealed no documented evidence the office of the Ombudsman was notified of the residents transfer to the hospital. Interview with the Administrator on 06/28/22 at 1:45 P.M. verified the Ombudsman had not been notified of any facility transfers to the hospital including Resident #263.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-06-29 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to ensure bed hold notices were provided to residents upon transfer to the hospital as required. This affected one (Resident #263) of one resident reviewed for hospitalization. This had the potential to affect all residents. The facility census was 70. Findings include: Review of the medical record revealed Resident #263 was admitted to the facility on [DATE] with diagnoses including dysphagia, lack of coordination, and muscle weakness. Review of the medical record revealed Resident #263 was sent to the hospital on [DATE] and was subsequently admitted to the hospital. Review of both the electronic and hard charts revealed no documented evidence Resident #263 was provided a bed hold notice upon transfer to the hospital. Interview with the Administrator on 06/28/22 at 1:45 P.M. verified no bed hold notice had been given to Resident #263 or any other resident upon transfer to the hospital.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-06-29 · 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 and interview, the facility failed to ensure care conferences were completed as required. This finding affected two (Resident's #10 and #37) of three residents reviewed for care planning. The facility census was 70. Findings include: 1. Review of Resident #10's medical record revealed he was admitted on [DATE] with diagnoses including muscle weakness, mixed hyperlipidemia, and major depressive disorder. Review of Resident #10's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he exhibited intact cognition and his sister was emergency contact number one and the care conference person. Review of Resident #10's progress notes from 02/17/22 to 06/27/22 did not reveal documented evidence a quarterly care conference was completed. Interview on 06/27/22 at 12:03 P.M. with Social Services Designee (SSD) #668 indicated the last care conference completed for Resident #10 was on 12/17/21 and she denied another care conference was completed quarterly as required. 2. Review 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2019-06-06 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to follow contact based precautions for Resident #40 to prevent the spread of infection. This affected one resident (Resident #40) and had the potential to affect all 19 residents (Resident #20, #27, #28, #8, #7, #65, #67, #78, #5, #12, #77, #68, #25, #43, #29, #4, #75, #11 and #40) of 19 residents residing on the unit. Findings Include: Record review revealed Resident #40 was admitted to the facility on [DATE] and was diagnosed with a urinary tract infection on 05/28/19. Resident #40's most recent quarterly Minimum Data Set (MDS) 3.0 assessment revealed the resident was always incontinent or urine and bowel. Resident #40's laboratory results dated [DATE] revealed she had escherichia coli (E-coli) extended-spectrum beta-lactamases (ESBL) bacteria in her urine. Resident #40's physician orders revealed she was ordered contact isolation precautions on 06/01/19. Observation on 06/03/19 at 10:10 A.M. with Licensed Practical Nurse (LPN) #100…

    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 before2019-06-06 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to maintain Resident #278's dignity when the resident's urinary catheter collection bag was uncovered in view from the hallway. This affected one resident (Resident #278) of one resident reviewed for indwelling catheters. The facility identified two residents residing in the facility with use of indwelling urinary catheters. Findings Include: Review of Resident #278's medical record revealed an admission date of 05/24/19 with a diagnosis including benign prostatic hyperplasia (enlarged prostate). Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident was alert and oriented and had an indwelling urinary catheter. Review of Resident #278's admission Immediate Need/Baseline Care Plan revealed the resident had an impaired urinary elimination pattern due to an enlarged prostate and needed an indwelling urinary catheter. The facility implemented the interventions to provide catheter 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-06-06 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to properly assess Resident #30's pressure ulcer. This affected one resident (Resident #30) of two residents reviewed for pressure ulcers. The facility identified six residents with pressure ulcers. Findings Include: Record review revealed Resident #30 was admitted to the facility on [DATE] with diagnoses including muscle weakness, paraplegia, and dementia. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 03/08/19 revealed the resident had no pressure ulcer. Review of the Weekly Skin Condition Data Tracking Sheet, dated 05/28/19, revealed an unstageable pressure ulcer, located on the left, lateral malleolus, measuring 2.5 centimeters (cm) length (l) by 2.0 cm width (w) with 0 cm depth (d). The wound bed was described as purple and non-blanching. Review of the Weekly Skin Condition Data Tracking Sheet, dated 06/04/19, revealed a Deep Tissue Injury (DTI), located on the left, lateral malleolus, measuring 1.0 centimeters (cm) length (l)…

    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 · D2019-06-06 · 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

    Based on record review and staff interview the facility failed to ensure Resident #53's behaviors were monitored related to the use of psychoactive medications. This affected one resident (Resident #53) of five residents reviewed for unnecessary medication use. Findings Include: Review of Resident #53's medical record revealed an admission date of 07/26/18 with admission diagnoses that included schizoaffective disorder and depression. Physician orders identified Prozac 50 milligram (mg) every day for depression initiated on 10/24/18 and Zyprexa (antipsychotic) 5 mg every day due to schizoaffective disorder initiated on 07/27/18. Review of Resident #53's care plan indicated a plan for mood and/or behavior symptoms related to depression and schizoaffective disorder had been developed. Interventions included monitoring/recording and reporting of any identified signs and symptoms of behaviors, depression and mood disturbance. Further review of the medical record found no evidence of any monitoring and documentation of monitoring of any behaviors for Resident #53. Interview 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2024-10-10 · tag F0851 — widespread
    Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to completely and accurately report staff hours worked for the Payroll Based Journal (PBJ) report. This had the potential to affect all 75 residents residing in the facility. Findings include: Review of the PBJ report revealed excessively low weekend staffing for the third quarter of 2024. Review of the staffing schedules for the nurses and State Tested Nurse Aides (STNA) for the third quarter of 2024 revealed on 05/24/24, 05/25/24 and 06/16/24 there was insufficient direct care staff in the facility to provided a minimum of 2.5 hours of direct care per resident per day. Interview on 10/10/24 at 2:00 P.M. with the Administrator revealed during the third quarter of 2024 when the facility utilized agency staff to cover shifts this data was not submitted to the corporate office for the PBJ so the data reported for the third quarter of 2024 was not accurate.

    Administration Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2022-06-29 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview, the facility failed to ensure the posted nurse staffing information was available daily as required. This finding had the potential to affect all 70 residents residing in the facility. Findings include: Observation on 06/26/22 at 2:10 P.M. with the Administrator of the posted nurse staffing information revealed the form was dated 06/09/22. Interview on 06/26/22 at 2:12 P.M. with the Administrator confirmed the posted nurse staffing form did not reflect the daily staffing information as required.

    Nursing and Physician Services Deficiencies · Deficient, Provider has plan 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

No federal fines in the current CMS record.

Part of a chain

This home belongs to CCH HEALTHCARE — 33 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 52.5+0.5 vs chain
Health inspection 3 of 52.4+0.6 vs chain
Staffing 2 of 52.5-0.5 vs chain
Quality measures 4 of 53.9+0.1 vs chain
The other 32 homes this chain runs (chain average 2.5★, per CMS)
1 of 5Carver Living CenterDurham, NC 1 of 5Countryside Manor Nursing And Rehabilitation LLCFremont, OH 1 of 5Harrison Pavilion Care CenterCincinnati, OH 1 of 5Meadowbrook Care CenterCincinnati, OH 1 of 5Smoky Mountain Health And Rehabilitation CenterPigeon Forge, TN 1 of 5The Greens at GastoniaGastonia, NC 1 of 5Valley Nursing and Rehabilitation CenterTaylorsville, NC 1 of 5Weakley Rehabilitation And Nursing CenterDresden, TN 2 of 5Cedars Of Lebanon Care CenterLebanon, OH 2 of 5Clovernook Health Care And Rehabilitation CenterCincinnati, OH 2 of 5Louisville Gardens Care CenterLouisville, OH 2 of 5Ridgewood Living & Rehabilitation CenterWashington, NC 2 of 5Solon Pointe At Emerald RidgeSolon, OH 2 of 5The Greens at HickoryHickory, NC 2 of 5The Greens at LincolntonLincolnton, NC 2 of 5The Greens at ViewmontHickory, NC 2 of 5Willow Ridge Of NCRutherfordton, NC 3 of 5Flint Ridge Nrsg & Rehab CtrNewark, OH 3 of 5Lincoln Crawford Care CenterCincinnati, OH 3 of 5Northcrest Rehab And Nursing CenterNapoleon, OH 3 of 5Pineville Rehabilitation and Living CenterPineville, NC 3 of 5Scarlet Oaks Nursing And Rehabilitation CenterCincinnati, OH 3 of 5The Greens at HendersonvilleHendersonville, NC 3 of 5The Greens at Pinehurst Rehabilitation & Living CePinehurst, NC 3 of 5The Greens at Spruce PinesSpruce Pine, NC 4 of 5Cedarview Care CenterLebanon, OH 4 of 5Sunrise Nursing Healthcare LLCAmelia, OH 4 of 5The Greens at Maple LeafStatesville, NC 4 of 5The Greens at WeavervilleWeaverville, NC 4 of 5Twilight Gardens Nursing And RehabilitationNorwalk, OH 5 of 5Locust Ridge Healthcare LLCWilliamsburg, OH 5 of 5The Greens at CabarrusConcord, NC

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 / managerTypeRoleShareSince
HORIZON HEALTHCARE GROUP LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST10%since 02/01/2022
MEADOW WIND HOLDING LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST15%since 02/01/2022
PHYTMBH LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST8%since 02/01/2022
YW MEADOWBROOK, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST19%since 02/01/2022
WOLMARK, RACHELIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST5%since 02/01/2022
WOLMARK, YEHUDAIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST19%since 02/01/2022
HAYS, RACHELIndividualW-2 MANAGING EMPLOYEEsince 02/01/2022
STERN, JACOBIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 02/01/2022

CMS files one row per role, so the 9 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.

4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$8.6M
Net patient revenuemost recent cost report
-3.2%
Operating marginrevenue minus expenses
$1.0M
Related-party expense12% of expenses
Who pays — share of resident-days
Medicaid 65%Medicare 9%Other / private 26%

This home reported $1.0M paid to related parties — landlords or management companies under common ownership — equal to about 12% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

$328per resident / day
operating cost
$9,970per month
≈ monthly operating cost
$318per 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 365665. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-10-10, 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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