Rose Lane Nursing And Rehabilitation
5425 High Mill Avenue NW, Massillon, OH 44646 · For profit - Corporation · 171 certified beds · (330) 833-3174 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0569)
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (35) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 4 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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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 | 5 of 5 |
| Long-stay residentspeople who live here | 5 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 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 2.0% | 5.3% | 15.4% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 4.7% | 6.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.2% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.4% | 0.4% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 6.8% | 30.1% | 6.5% | typical |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.7% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 0.9% | 6.1% | 16.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 34.6% | 25.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.3% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 21.0% | 21.4% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 6.2% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 96.6% | 75.6% | 79.4% | better |
| Long-stay hospitalizations per 1,000 resident days | 0.54 | 1.73 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.83 | 1.80 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
49.1% 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 31 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.24 therapist hours per resident per day in 2026Q1 — more than 33% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 49.1%CMS range 34.4–64.0 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not 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 discharge | not 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 discharge | not 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 identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not 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 stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not 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 SNFs | 1.32 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 171 beds and averages 160.5 residents a day — about 94% occupied, or roughly 10 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.21 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.63 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.79 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.92 hrs/resident/day on weekends vs 3.33 on weekdays — 12% thinner on weekends. RN hours go from 0.69 to 0.49 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 45% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
35 citations, most serious first. The 12 most serious are shown; the remaining 23 are one tap away and print in full.
- Immediate jeopardy · Lcited before2021-09-13 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, review of Nursing Home Guidance from the Centers for Disease Control (CDC), review of the Centers for Medicare and Medicaid Services (CMS) Quality Safety and Oversight (QSO) Memo, review of the facility COVID-19 policy, observations and interviews, the facility failed to implement effective and recommended infection control practices to prevent the spread of COVID-19. This resulted in Immediate Jeopardy on 08/30/21 when the facility did not implement appropriate personal protective equipment (PPE) including disposable gowns, gloves, N95 respirator masks and goggles/face shields while caring for residents, did not ensure a resident who tested positive for COVID 19 (Resident #47) did not reside in a room with a resident who tested negative (Resident #126) without the guardian's knowledge. The facility failed to properly disinfect high touch areas including staff break rooms 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.
- Actual harm · Gcited before2024-01-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, observation, interview, and facility policy review, the facility failed to provide Resident #49 adequate assistance when transferring resulting in a fall with major injury. Actual harm occurred on 01/13/24 when Resident #49, who required assistance of two people for transfers, was transferred from the toilet to a shower chair by one person, resulting in a fall and non displaced fracture on left metacarpal and closed fracture of radius and ulna in left forearm, requiring orthopedic surgery. This affected one (Resident #49) of three residents reviewed for falls. The census was 159. Findings Include: Resident #49 was admitted to the facility on [DATE]. Her diagnoses included but were not limited to hemiplegia and hemiparesis, muscle weakness, need for assistance with personal care chronic obstructive pulmonary disease, cerebrovascular disease, atrial…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-03-27 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, review of the facility policy and review of the resident handbook, the facility failed ensure a clean, sanitary and homelike environment. This affected 12 residents (#32, #37, #40, #70, #77, #109, #110, #129, #131, #148, #149 and #159) out of 30 residents residing on the 300-hall (memory care). The facility census was 167.Findings include: Observation on 03/27/26 from 10:08 A.M. to 10:28 A.M. with Housekeeping Supervisor (HS) #303 revealed the following areas of concern:- In Resident #149's room, there was feces on the toilet leading down the bowl of the toilet, and the toilet looked like it had not been cleaned in a while.- In Resident #110's room, there was feces on the floor in front of the toilet.- In Resident #109's room, there was feces over the toilet and an open soiled brief filled with feces in the corner of the bathroom.- In Resident #32 and Resident #37's bathroom, there was feces on and in the toilet, and the toilet was visibly dirty.- In Resident #70, Resident #131 and Resident #159's bathroom, there was urine puddled on the riser over…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-24 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, facility policy, and self-reported incident (SRI) review, the facility failed to timely report an injury of unknown origin. This affected one resident (Resident #175) of three residents reviewed for abuse. The facility census was 151. Findings included: Review of the closed medical record for Resident #175 revealed an admission date of 06/05/25 with diagnosis including but not limited to abscess of bursa right hip, methicillin resistant staphylococcus aureus infection, and Alzheimer's Disease. Resident #175 was discharged to hospital of 06/15/25. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #175 was rarely/never understood. Resident #175 was dependent on staff for all activities of daily living (ADL'S) and always incontinent of bladder and bowel. Review of the care plan dated 06/06/25 revealed Resident #175 had a ADL/self-care deficit due to weakness, dementia, bacteremia, and status post incision and drainage (I/D) right hip.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-11-19 · tag F0688 — failed to keep residents mobile / prevent decline — patternProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record reviews, policy review, observations, and interview, the facility failed to ensure services were provided to maintain or improve a resident's range of motion. This affected four (Residents #58, #91, #125 and #127) of five residents reviewed for limited range of motion. Findings include: 1. Review of Resident #58's medical record revealed a diagnoses of right side weakness and paralysis following a stroke and right hand contracture. Review of a care plan initiated 08/28/20 revealed Resident #58 had a self care deficit due to post stroke and right sided weakness and chronic obstructive pulmonary disease. An intervention dated 10/13/20 indicated a right resting hand splint was to be donned six to eight hours as tolerated. Check skin integrity before applying and after removing. A care plan initiated 12/02/20 revealed Resident #58 was at risk for decline in active and passive range of motion. An intervention dated 10/28/22 indicated an intervention for Restorative Nursing Services (RNS) for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-11-19 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, review of schedules and time punches, and interview, the facility failed to ensure there was sufficient staff to consistently provide restorative programs and to respond to call lights in a timely manner. This affected two (Residents #58, #127) of six residents reviewed for activities of daily living and two (Residents #58 and #127) of five residents reviewed for range of motion and one additional resident (Resident #140) who was identified as not having the call light responded to timely. This had the potential to affect all residents. Findings include: 1. During a resident council meeting with Residents #4, #10, #19, #28, #31, #33, #57, #64, #117 and #126 the residents had a majority consensus that the facility did not have sufficient staff with multiple residents reporting it could take up to an hour to get assistance with some residents reporting they were incontinent as a result. Residents reported there had been restorative programs that were not provided…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-11-19 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. On 11/14/23 at 12:10 P.M., observation of the medication room in the 400 hall revealed one box of Multistix urinalysis dip sticks to test for urinary tract infections with an expiration date of 08/31/23. Licensed Practical Nurse (LPN) #410 verified the urinalysis test strips were expired. Observation of the medication cart in the 400 hall revealed a bottle of Biotene mouth wash, labeled for Resident #46, had an expiration date of 08/03/22. At the time of observation, LPN #410 verified the Biotene was expired. 3. On 11/14/23 at 2:55 P.M., observation of the medication room in the 100 hall revealed an open one milliliter vial of Tubersol (a multi-dose solution used for tuberculosis testing) in the refrigerator. The vial of tubersol was not labeled as to when it was opened. At the time of observation, Registered Nurse (RN) #404 verified the vial was open and was not labeled as to when it was opened. 4. On 11/15/23 at 9:55 A.M., observation of the medication storage room in the 200 hall revealed a bottle of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-11-19 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake 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 and interviews the facility failed to maintain a clean, sanitary environment This had the potential to affect eight residents (Resident #7, #29, #36, #84, #87, #100, #103, #125) for environment and all 18 residents (Resident #1, #2, #13, #20, #25, #42, #70, #74, #75 #78, #89, #99, #112, #122, #123, #126, #134, #143) on the 200 unit who used the shower room. The facility census was 155. Findings Included: 1. Observations on 11/13/23 at 9:05 A.M., 1:46 P.M., and 3:00 P.M. revealed there was fecal matter on the toilet seat and the floor in front of the toilet in the shared bathroom of Resident #29 and #103. On 11/13/23 at 3:00 P.M. an interview with State Tested Nursing Assistant (STNA) #406 verified the fecal matter on the toilet seat and the floor in front of the toilet in the shared bathroom of Resident #29 and #103. She stated the 100 and 200 units did not have a housekeeper today so it was the aides' responsibility to clean up any messes. On 11/15/23 at 10:45 A.M. an interview with Housekeeping Director #317 revealed all the units should have at least one…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-19 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and interview with staff the facility failed to ensure Resident #36's call light was within reach. This affected one resident (Resident #36) of 36 residents observed for call lights. Findings included: Review of the medical record revealed Resident #36 was had an admission date of 06/11/14. Diagnoses included heart failure, borderline personality disorder, chronic obstructive pulmonary disease, major depressive disorder, schizophrenia, asthma, post-traumatic stress disorder, and auditory hallucinations. Review of the plan of care dated 05/29/14 revealed Resident #36 received psychotropic medication with potential for falls, injury potential for harmful side effects relate to schizophrenia, depression and anxiety. Intervention included to keep (the) call light within reach. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #36 had moderately impaired cognition and she had no upper extremity impairment. Observations on 11/13/23 at 9:44 AM…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-19 · tag F0569 — isolatedNotify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
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 staff interview the facility failed to ensure resident funds were conveyed timely upon resident discharge from the facility. This affected two residents (Resident #410 and #411) of two residents reviewed for funds conveyance. The facility census was 155. Findings Include: 1. Resident #410 was admitted to the facility on [DATE] with diagnoses including, but not limited to, vascular dementia, generalized anxiety disorder, schizophrenia, and major depressive disorder. Resident #410 expired at the facility on [DATE]. Review of the business records for Resident #410 revealed a check in the amount of $50.13 was dispersed to the State of Ohio Treasurer on [DATE]. 2. Resident #411 was admitted to the facility on [DATE] with a readmission date of [DATE] with diagnoses including, but not limited to, Alzheimer's Disease, major depressive disorder, diabetes mellitus. Resident #411 expired at the facility on [DATE]. Review of the business records for Resident #411 revealed a check in the amount of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-19 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
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, policy review, and interview, the facility failed to ensure restorative programs for ambulation and/or transfers were consistently implemented and evaluated for two (Residents #58 and #127) of six residents reviewed for activities of daily living. The facility identified nine residents on restorative ambulation or transfer programs. The census was 155. Findings include: 1. Review of Resident #58's medical record revealed diagnoses including right sided weakness and paralysis following a stroke, chronic obstructive pulmonary disease, polyneuropathy, atrial fibrillation, anemia, and osteoarthritis. Review of a physical therapy (PT) Discharge summary dated [DATE] indicated interventions provided during PT included activities to promote safe ambulation. Resident #58 had demonstrated improved tolerance to transfers and mobility with a hemi-walker (designed for individuals with the use of only one hand or arm. Lighter than a walker and more stable than a cane) with minimal episodes of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-19 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the medical record, and interview the facility failed to ensure Resident #134 was transported to a non-emergent emergency room visit for evaluation after a fall and wound dressings were applied as ordered for Resident #46. This affected one resident (Resident #134) of eight residents reviewed for accidents and one resident (Resident #46) of three residents reviewed for pressure ulcers. The census was 155. Findings included: Review of the medical record revealed Resident #134 was admitted to the facility on [DATE]. Diagnoses included lumbar fracture, diabetes, major depressive disorder, osteoarthritis bilateral knees, respiratory failure, and kidney disease. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #134 had intact cognition. Review of the progress note dated 08/25/23 at 2:30 A.M. revealed the nurse was informed by the nursing assistant after answering his call light Resident #134 stated he had fallen out of bed. Upon entering his room he…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 23 citations
- Potential for harm · Dcited before2023-11-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the medical record and interview the facility failed to ensure fall interventions were in place for Resident #36, and failed to ensure medications were not left at the bedside for Residents #147 and #355. This affected three residents (Resident #36, #147 and #335) of eight residents reviewed for accidents. Findings included: 1. Review of the medical record revealed Resident #36 was admitted to the facility on [DATE]. Diagnoses included heart failure, borderline personality disorder, chronic obstructive pulmonary disease, suicidal ideation, major depressive disorder, schizophrenia, asthma, post-traumatic stress disorder, and auditory hallucinations. Review of the physician's orders revealed Resident #36 had an order to have a floor mat to the open side of the bed dated 01/03/23. Review of the plan of care dated 01/16/23 revealed Resident #36 had a potential for falls related to psychotropic medication use, decreased cognition, weakness, decreased mobility, obesity, and arthritis.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-19 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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 observation, medical record review, review of the narcotic count sheet and interview the facility failed to ensure residents were free from unnecessary psychotropic medications and failed to ensure medications were administered per physician orders. This affected one resident (Resident #66) of five residents reviewed for unnecessary medications. The census was 155. Findings included: Review of the medical record revealed Resident #66 was admitted to the facility on [DATE]. Diagnoses included dementia with behavioral disturbance, depression, psychosis, insomnia, post traumatic stress disorder, and chronic pain. Review of the comprehensive Minimum Data Set assessment dated [DATE] revealed Resident #66 had severely impaired cognition. Review of the November 2023 physician's orders revealed Resident #66 had an order for oxycodone hydrochloride (HCL) (pain medication) five milligrams (mg) one or two tablets every four hours as needed for pain dated 02/19/23. He had an as needed order for Ativan (anti-anxiety…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-19 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, the facility failed to maintain accurate medical records. This affected three (Residents #96, #125 and #138) of 34 resident records reviewed for accurate medical records The census was 155. Findings include: 1. Review of Resident #125's medical record revealed diagnoses including stroke, heart failure and atrial fibrillation. On 09/08/23 an order was written for a resting left hand splint with wear time as tolerated. A quarterly Minimum Data Set (MDS) assessment revealed Resident #125 had functional limitation in range of motion of both lower extremities and one upper extremity. Resident #125 denied pain over the prior five days. Observations on 11/13/13 at 11:32 A.M., 2:09 P.M. and 2:20 P.M. revealed Resident #125 was observed lying in bed with no splint applied. On 11/13/25 at 2:25 P.M., State Tested Nursing Assistant (STNA) #428 stated she had never seen Resident #125 wear a splint and she had not attempted to apply it. STNA #428 indicated she was unsure about Resident #125's ability to tolerate the splint. Subsequent…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-08-15 · tag F0726 — failed to have competent, trained nursing staff — patternEnsure 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
Based on observations and interviews, the facility failed to ensure all agency staff were oriented to the call light system to assist residents timely. This affected 13 residents (Resident #8, #13, #27, #36, #49, #57, #83, #88, #91, #95, #106, #121 and #123) of 58 residents reviewed for resident call system. Finding Include: Interview on 08/14/23 at 2:10 P.M. with agency State Tested Nurses Assistant (STNA) #307 revealed she was the only aide on the 600-Hall, for 13 residents. STNA #307 stated she has been in all of her resident's rooms every two hours. STNA #307 was asked if call lights were being answered timely and she responded, no call lights have gone off. STNA #307 verified she did not realize the lights above the resident doors did not work and that she was supposed to have a call light phone with her. STNA #307 stated this was her first day in the building as she was contracted through a staffing agency, and no one told her that she was to have a call light phone with her and that the lights above resident doors do not work. STNA #307 stated she just found out about the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-08-15 · tag F0919 — failed to provide a working call system — patternMake 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
Based on observations and interviews the facility failed to ensure the resident call light system was functioning properly at all times. This affected 13 residents (Resident #8, #13, #27, #36, #49, #57, #83, #88, #91, #95, #106, #121 and #123) of 58 residents reviewed for resident call system. Finding Include: Interview on 08/14/23 at 2:10 P.M. with agency State Tested Nurses Assistant (STNA) #307 revealed she was the only aide on the 600-Hall, for 13 residents. STNA #307 stated she has been in all of her resident's rooms every two hours. STNA #307 was asked if call lights were being answered timely and she responded, no call lights have gone off. STNA #307 verified she did not realize the lights above the resident doors did not work and that she was supposed to have a call light phone with her. STNA #307 stated this was her first day in the building and no one told her that she was to have a call light phone with her and that the lights above resident doors do not work. STNA #307 stated she just found out about the call light phone a few minutes ago (12:00 P.M.) and she has been on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2021-09-13 · tag F0835 — failed to run the facility competently — widespreadAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
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 the administration used its resources effectively and efficiently to ensure comprehensive and effective infection control policies and practices were developed and implemented to prevent the spread of COVID-19. This affected all 150 facility residents. Findings include: The facility failed to implement effective and recommended infection control practices and failed to use Personal Protective Equipment (PPE) appropriately to decrease the risk of the spread of Covid-19 within the facility. The facility did not effectively utilize PPE including disposable gowns, N95 respirator masks, and goggles/face shields while caring for residents, did not assure staff were completing appropriate hand hygiene while caring for residents, did not ensure a resident's guardian was notified when the resident refused to move to from a room with Covid- 19 positive resident, did not consistently and thoroughly screen visitors and staff for Covid -19, did not monitor visitation, and did not properly disinfect high touch areas…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2021-09-13 · tag F0867 — failed to act on quality-improvement findings — widespreadSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
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 ensure identified concerns were timely and appropriately addressed through the Quality Assurance and Performance Improvement committee. This had the potential to affect all 150 residents residing at the facility. Findings include: During the annual survey, concerns related to infection control practices were identified, specifically the facility failed to implement effective and recommended use of Personal Protective Equipment (disposable gowns, N95 respirator masks, and goggles/face shields) while caring for residents to decrease the risk of the spread of Covid-19 within the facility. The facility did not assure staff were completing appropriate hand hygiene while caring for residents, did not ensure a resident's guardian was notified when the resident refused to move from a room with a resident who tested positive for Covid-19, did not consistently and thoroughly screen visitors and staff for Covid -19 and did not monitor visitation during the outbreak of Covid-19. The facility failed to properly disinfect…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2021-09-13 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interview, and review of manufacturer information for sanitizer use, the facility failed to prepare puree food under sanitary conditions. This affected 12 residents (Residents #14, #26, #36, #55, #56, #74, #88, #91, #105, #120, #127, and #142) of 12 residents who received puree diets. The facility identified 148 residents who received diets from the kitchen. Findings include: On 09/01/21 beginning at 9:30 A.M., [NAME] #411 was observed pureeing ham. From 9:34 A.M. to 9:35 A.M., [NAME] #411 was observed washing, rinsing and sanitizing the Robo Coup (food processor) canister, blades and lid. The items were shaken to remove excess water. [NAME] #411 returned to the food processor and pureed the scalloped potatoes. Between 9:38 A.M. and 9:40 A.M., [NAME] #411 washed, rinsed, and sanitized the canister, blades and lid. The items were shaken to remove excess water. [NAME] #411 returned to the food processor to puree corn. On 09/01/21 at 9:45 A.M., [NAME] #411 verified she shook the items to remove excess water and did not permit the items to air dry. On 09/01/21 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.
- Potential for harm · D2021-09-13 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and observation the facility failed to ensure adequate incontinence care was provided for two residents (#27 and #56) of two reviewed for incontinence care. The facility census was 150. Finding include: 1. Review of Resident #56's medical records revealed an admission date of 10/22/13 with diagnoses that included muscle weakness, need for personal assistance and difficulty walking. Review of the MDS assessment dated [DATE] revealed Resident #56 had impaired cognition, required extensive assistance with bed mobility, toileting and personal hygiene, had total dependence for transfers and the resident was incontinent of bowel and bladder. Review of the care plan dated 07/01/21, revealed Resident #56 was incontinent. Interventions included encourage resident to hold urine until next scheduled time, but assist if required, pericare when incontinent and check and change every two hours. Review of Resident #56's physician orders for August 2021 revealed an order for check and change…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-09-13 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to discard expired insulin. This affected one (Resident #3) of three residents (Resident #3, #13 and #30) reviewed for insulin medication in the 500 medication cart. The facility census was 150. Findings include: Medical record review of Resident #3 revealed an admission date of [DATE] with diagnoses including diabetes mellitus with hyperglycemia, visual loss of both eyes, and history of traumatic brain injury. Resident #3 had a physician's order dated [DATE] for Humalog 100 unit/milliliter (insulin) at breakfast, lunch and dinner per sliding scale. Review of the resident's medication administration record revealed the Humalog was administered as ordered. Observation on [DATE] at 9:44 A.M. of the medication cart on the 500 unit with Registered Nurse (RN) #517, revealed a bottle of Insulin Lispro (Humalog) was dated as opened on [DATE]. Interview with RN #517 at time of observation verified Resident #3's Insulin Lispro (Humalog) was dated 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.
- Potential for harm · Ecited before2019-11-07 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide a homelike environment for Residents #16, #17, #40, #80, and #128. This affected five Residents (#16, #17, #40, #80, and #128) out of 148 residents. Facility census was 148. Findings include: 1. Review of the medical record revealed Resident #16 was admitted on [DATE] with diagnosis that included hemiplegia/hemiparesis and dementia. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #16 had short and long term memory problems. Observation on 11/04/19 at 9:51 A.M. revealed there were gouges and a hole in the wall under the residents heating and air conditioning unit. Interview on 11/07/19 at 9:10 A.M. Assistant Administrator #802 verified there were gouges and a hole in the wall under Resident #16's heating and air conditioning unit. 2. Review of the medical record revealed Resident #17 was admitted on [DATE] with diagnoses that included dementia, anxiety, and restlessness. The annual MDS dated [DATE] revealed Resident #17 had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2019-11-07 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to ensure resident (Resident #43, #97, #55, #107, #116, #13, #48, #110, #191, #85, #63, #37, #87, #122, #21, #16, #6, #19, #135, #47, #44, #900, #52, #192, #91, #136, #28, #102, #31, #7 and #121) preferences were maintained and meals were served as planned. This affected 32 residents, Resident #43, #97, #55, #107, #116, #13, #48, #110, #191, #85, #63, #37, #87, #122, #21, #16, #6, #19, #135, #47, #44, #900, #52, #192, #91, #136, #28, #102, #31, #7 and #121, out of 32 who provided preferences and/or were not given the opportunity to receive the items they desired for their meals. The facility census was 148. Findings include: Review of Resident #43's meal tickets revealed white bread only. Review of Resident #97's meal tickets revealed no cheese and two packets of sugar substitute. Review of Resident #55's meal tickets revealed two bowls of cold cereal for breakfast. Review of Resident #107's meal tickets revealed the resident was on a pureed diet and to provide an extra side of gravy with each meal and gravy 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.
- Potential for harm · E2019-11-07 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview the facility failed to ensure food was palatable on the dementia unit. This had the potential to affect the 28 non interviewable residents (Resident's #190, #123, #129, #130, #93, #87, #117, #113, #136, #65, #18, #111, #119, #127, #26, #32, #64, #28, #44, #42, #122, #45, #81, #36, #106, #75, #15 and #191) who received meals from the facility. The facility census was 148. Findings include: On 11/04/19 observation of the dementia unit passing of the lunch meal to the 28 residents (Resident's #190, #123, #129, #130, #93, #87, #117, #113, #136, #65, #18, #111, #119, #127, #26, #32, #64, #28, #44, #42, #122, #45, #81, #36, #106, #75, #15 and #191) revealed the staff started passing the trays at 12:12 P.M. and did not finish passing the last tray until 12:35 P.M. On 11/06/19 observation of tray line from 4:11 P.M. until 5:45 P.M., revealed the milk cartons and prepoured thickened drinks were observed in bins with a minimum amount of ice not covering the majority of the drinks. A rack was observed with cooking sheets holding items such as salad, pears,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-11-07 · tag F0675 — failed to support quality of life — isolatedHonor each resident's preferences, choices, values and beliefs.
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 and record review revealed the facility failed to ensure Resident #107's concerns related to his care and services were being addressed and the resident had the opportunity to actively participate in decision making. This affected one, Resident #107, of one resident reviewed for quality of life. The facility census was 148. Findings include: 1. Resident #107 was admitted to the facility on [DATE] with diagnoses which included aspiration pneumonitis, cerebral vascular accident (CVA) resulting in aphasia and paralysis (quadriplegia). The resident was his own responsible party. He was alert and oriented and was able to communicate utilizing an eye gaze communication device (a computer programmed to activate typing based on the residents eye movement). Review of the admission Minimum Data Set (MDS) 3.0 dated 04/24/19 revealed a brief assessment for mental status (BIMS) should not be completed because the resident was not understood. Further review of the quarterly MDS 3.0 dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-11-07 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure Resident #107 had affective interventions offered, preferences obtained and ensuring interventions in place was accepted by the resident who sustained significant weight loss. The facility failed to ensure Resident #192's preferences were obtained when the resident sustained weight loss. This affected two, Resident #107 and Resident #192, of three residents reviewed for nutrition. The facility census was 148. Findings include: 1. Resident #107 was admitted to the facility on [DATE] with diagnoses which included aspiration pneumonic, cerebral vascular accident (CVA) resulting in aphasia and paralysis (quadriplegia). The resident was his own responsible party and was able to communicate utilizing an eye gaze device (the computer was programmed to activate typing based on the residents eye movement). Review of the physicians order dated 04/17/19 revealed the resident was on a pureed diet with nectar thick liquids (NTL). 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.
- Potential for harm · D2019-11-07 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when 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 observation, review of facility policy, review of the medical record and staff interview the facility failed to follow physician's orders for Resident #133 and # 292 for oxygen therapy. This affected two residents (Resident #133 and 292) of 14 residents on oxygen therapy. The facility census was 148. Findings include: 1. Review of the medical record revealed Resident #292 was admitted to the facility on [DATE] with the diagnoses of dysphagia, neuromuscular dysfunction of the bladder, Parkinson's disease, chronic obstructive pulmonary disease, dependence on supplemental oxygen, neck fracture, acute and chronic respiratory failure, gastrostomy, diabetes, and benign prostatic hyperplasia. There was no Minimum Data Set 3.0 assessment available. Review of the November 2019 physicians orders revealed Resident #292 had orders dated 11/04/19 for oxygen face mask continuously and may use nasal cannula during the day if refuses mask and an order dated 10/29/19 for ipratropium-albuterol solution 0.5/2.5 milligrams…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-11-07 · tag F0710 — isolatedObtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview the facility failed to have a physician visit Resident #59. This affected one resident (Resident #59) of 36 resident reviewed for physicians visits. Findings include: Review of the medical record revealed Resident #59 was admitted to the facility on [DATE] with the diagnoses of cerebral infarction, vascular dementia, anxiety disorders, psychosis, hemiplegia, congestive heart failure, benign neoplasm of the adrenal gland, Wernicke's encephalopathy, major depressive disorder, and chronic obstructive pulmonary disease. Review of the significant change Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #59 had moderately impaired cognition and required extensive assistance with all his activities of daily living. Review of the medical record revealed the physician had not seen the resident since admission. The resident was only seen by the nurse practitioner. Review of the Physician/NP Progress notes revealed the nurse practitioner had visited Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-11-07 · tag F0712 — isolatedEnsure that the resident and his/her doctor meet face-to-face at all required visits.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview the facility failed to alternate physician and nurse practitioner visit Resident #59. This affected one resident (Resident #59) of 36 resident reviewed for physicians visits. The facility census was 148. Findings include: Review of the medical record revealed Resident #59 was admitted to the facility on [DATE] with the diagnoses of cerebral infarction, vascular dementia, anxiety disorders, psychosis, hemiplegia, congestive heart failure, benign neoplasm of the adrenal gland, Wernicke's encephalopathy, major depressive disorder, and chronic obstructive pulmonary disease. Review of the significant change Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #59 had moderately impaired cognition and required extensive assistance with all his activities of daily living. Review of the medical record revealed the physician had not seen the resident since admission. The resident was only seen by the nurse practitioner. Review of the Physician/NP Progress notes…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-11-07 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and medication administration policy and procedure, the facility also failed to ensure open influenza vials were dated, and medications were properly stored in the medication carts. This affected 72 out of 148 residents. Facility census was 148. Findings include: 1. Observation on 11/07/19 at 12:14 P.M. of the 400 Hall medication cart revealed five loose tablets in the drawer, the drawer had four holes in the bottom of the drawer that would allow the tablets to fall through onto the floor unnoticed. An interview at this time Licensed Practical Nurse (LPN) #633 verified there were five loose tablets in the the medication cart. 2. Observation on 11/07/19 at 12:19 P.M. of 400 Hall medication room revealed one five milliliter multi-dose vial of Flucelvax Quadrivalent was open and not dated when it was opened. An interview at this time LPN #633 verified the vial was not dated as to when it had been opened. 3. Observation on 11/07/19 at 12:30 P.M. of the 300 Hall medication room revealed one five milliliter multi-dose vial of Flucelvax…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2023-11-19 · tag F0623 — patternProvide 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 — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of transfer notices, policy review, and interview, the facility failed to ensure information regarding the reason for hospital transfer was documented on the transfer notice. This affected four residents (Residents #4, #16, #125 and #151) of 31 residents reviewed for hospitalization during the initial phase of the survey. The census was 155. Findings include: 1. Review of Resident #16's medical record revealed diagnoses including Parkinson's disease, schizoaffective disorder/bipolar type, type two diabetes mellitus, anxiety disorder and chronic obstructive pulmonary disease. Review of a nursing note dated 03/07/23 at 9:30 P.M. indicated Resident #16's cheeks were flushed. Resident #16's tremors increased and her fingers were cyanotic (blue discoloration due to a lack of oxygen). Resident #16 was alert and oriented. Resident #16's oxygen saturation was originally 56-76% (normal range 90%-100%), pulse was 102 (beats per minute), blood pressure was 137/104, temperature was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2023-11-19 · tag F0625 — patternNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of transfer notices, and interview, the facility failed to ensure information was provided regarding the length of time a resident's bed would be held or the cost to do so when residents were transferred to the hospital. This affected four (Residents #4, #16, #125 and #151) of 31 residents reviewed for hospitalization during the initial phase of the survey. Findings include: 1. Review of Resident #16's medical record revealed diagnoses including Parkinson's disease, schizoaffective disorder/bipolar type, type two diabetes mellitus, anxiety disorder and chronic obstructive pulmonary disease. Review of a nursing note dated 03/07/23 at 9:30 P.M. indicated Resident #16's cheeks were flushed. Resident #16's tremors increased and her fingers were cyanotic (blue discoloration). Resident #16 was alert and oriented. Resident #16's oxygen saturation was originally 56-76% (normal 90-100%), pulse was 102 beats per minute, blood pressure was 137/104, temperature was 98.2 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.
- No harm found · Ccited before2019-11-07 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to ensure proper hand hygiene during tray line. This had the potential to affect the 147 residents who received food from the kitchen. Resident #292 had an order for nothing by mouth. The facility census was 148. Finding include: On 11/06/19 observation of tray line from 4:11 P.M. until 5:45 P.M., revealed the milk cartons and prepoured thickened drinks were observed in bins with a minimum amount of ice not covering the majority of the drinks. A rack was observed with cooking sheets holding items such as salad, pears, tangerines, cottage cheese and other items that were supposed to be served cold. There was no evidence the temperatures (T) of any of the cold items were obtained prior to starting tray line. Further observations revealed there were four dietary staff on the line. Dietary Aide (DA) #696 was observed pouring drinks and covering them with lids and placing them on the residents trays. DA #696 did not have on any gloves and had long painted fingernails (far exceeding one-eighth of an inch). DA #696…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · Ccited before2019-11-07 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to ensure implementation of monitoring for Legionella. This had the potential to affect the 148 residents residing in the facility. Findings include: On 11/07/19 at 2:50 P.M., interview with the Maintenance Director (MD) #709 revealed the facility did not have documented evidence of flushing sinks and running showers for 10 minutes in resident rooms and treatment areas that had been vacant for more than three days. The facility did not have eyewash stations (as indicated in the policy). The facility did not have documentation to show monitoring of water heaters to ensure proper operating temperatures. The facility did not check chemical disinfectant residual measurements on either the hot or the cold water loops of the water system. Review of the legionella policy, revised 01/07/17, revealed the procedures for the inspection of and inspection schedule for water-containing vessels and systems components included the environmental services employees would flush sinks and run showers for 10 minutes in resident rooms and treatment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to SPRENGER HEALTH CARE SYSTEMS — 12 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 3.3 | -1.3 vs chain |
| Health inspection | 1 of 5 | 3.1 | -2.1 vs chain |
| Staffing | 3 of 5 | 2.8 | +0.2 vs chain |
| Quality measures | 5 of 5 | 4.5 | +0.5 vs chain |
The other 11 homes this chain runs (chain average 3.3★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| BLUESKY HEALTHCARE INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 09/21/2010 |
| HUTSENPILLER, WENDIE | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 18% | since 03/01/2011 |
| MALANOWSKI, KENNETH | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 20% | since 03/21/2011 |
| SPRENGER, NICOLE | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 31% | since 03/21/2011 |
| SPRENGER, TRACEY | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 31% | since 03/21/2011 |
| FOX, EMILY | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/31/2024 |
| KUHN, SHANNON | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/31/2024 |
| MALANOWKI, BRANDON | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/31/2024 |
| CMS & CO. MANAGEMENT SERVICES, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/22/2001 |
| COURTOCK, MELISSA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/02/2002 |
| DIDOMENICO, RICHARD | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/26/2024 |
| EPPERLY, ROBERT | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/20/2022 |
| GOLLINGER, KRISTEN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/13/2000 |
| MARINO-FREETAGE, JAIME | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/01/2011 |
| MICALE, JACOB | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/20/2023 |
| MILLER, KIMBERLY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/01/2025 |
| WOOTEN, KAREE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/30/2024 |
| BSH INVESTMENTS LLC | Organization | ADP OF THE SNF | — | since 09/21/2010 |
| CITRIN COOPERMAN AND COMPANY, LLP | Organization | ADP OF THE SNF | — | since 02/01/2025 |
| DELTA HEALTH CARE CONSULTANTS, INC. | Organization | ADP OF THE SNF | — | since 01/01/2008 |
| HUNTINGTON | Organization | ADP OF THE SNF | — | since 03/01/2011 |
| ROSE LANE RENTAL PROPERTIES, LLC | Organization | ADP OF THE SNF | — | since 09/21/2010 |
| WELLSPRING STAFFING, INC. | Organization | ADP OF THE SNF | — | since 10/15/2021 |
| SAWULSKI, JENNIFER | Individual | ADP OF THE SNF | — | since 03/21/2011 |
| SKIDMORE, JODI | Individual | ADP OF THE SNF | — | since 03/21/2011 |
CMS files one row per role, so the 44 rows in the source record cover these 25 parties — each is shown once here with every role it holds. Nothing is omitted.
8 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $2.2M paid to related parties — landlords or management companies under common ownership — equal to about 14% 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
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OH
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Ohio Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 365289. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2023-11-19, 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.