Life Care Center Of Medina
2400 Columbia Rd, Medina, OH 44256 · For profit - Limited Liability company · 149 certified beds · (330) 483-3131 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (29% vs 45% nationally) — better care continuity
- 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 (F0570)
- a high number of inspection citations overall (33) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- 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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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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 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 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 | 11.3% | 5.3% | 15.4% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 6.0% | 6.2% | 5.4% | worse |
| 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 | 0.5% | 0.4% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 20.2% | 30.1% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 4.7% | 3.2% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 9.4% | 6.1% | 16.1% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 32.3% | 25.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 86.4% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.8% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 21.1% | 21.4% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 12.2% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.9% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 42.6% | 75.6% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 29.8% | 24.9% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 10.5% | 12.9% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.83 | 1.73 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.37 | 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.
58.0% 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 107 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 82.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 79 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.31 therapist hours per resident per day in 2026Q1 — more than 49% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 16% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 58.0%CMS range 46.4–68.4 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.3%CMS range 8.4–15.2 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 82.3% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 72.2% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 64.6% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 98.2% | 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 | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 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 | 1.9% | 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 | 6.1%CMS range 3.6–11.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.95 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 149 beds and averages 108.9 residents a day — about 73% occupied, or roughly 40 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.80 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.76 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.27 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.55 hrs/resident/day on weekends vs 3.90 on weekdays — 9% thinner on weekends. RN hours go from 0.91 to 0.40 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 29% is below the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
33 citations, most serious first. The 10 most serious are shown; the remaining 23 are one tap away and print in full.
- Potential for harm · Dcited before2026-03-13 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility policy, the facility failed to ensure appropriate infection control measures were maintained during wound care for Resident #91, who required Enhanced Barrier Precautions (EBP). This affected one resident (#91) of three residents reviewed for infection control. The facility identified seven residents residing in the Memory Care Unit who required EBP. The facility census was 105. Findings include: Record review for Resident #91 revealed an admission date of 12/09/25. Diagnoses included encounter for orthopedic aftercare following surgical amputation, diabetes mellitus, infection and inflammatory reaction due to indwelling urethral catheter, urinary retention, long term use of antibiotics, peripheral vascular disease, and acquired absence of left toes. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #91 was cognitively intact. Resident #91 used a walker and had impairment on one side 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 · Ecited before2024-01-25 · 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 observation and interview the facility failed to maintain a clean and sanitary kitchen and nursing unit refrigerator. This had to the potential to affect 116 of 118 residents in the facility as Residents #4 and #425 received nothing by mouth. The facility census was 118. Findings include: During the initial tour of the kitchen on 01/22/24 from 9:09 A.M. to 9:45 A.M. with Dietary Manager (DM) #361 revealed the outside door of the reach in cooler had various food stains/smears and the inside of the cooler's bottom shelf had various food crumbs and debris. On the counter where the coffee machine was located were dried coffee stains on the counter and the along the side of the coffee maker. The floor by the oven was dirty with dried food and small bits of paper on the floor. Interview on 01/22/24 between 9:09 A.M. to 9:45 A.M. with DM #361 verified the above identified findings. Observation on 01/23/24 at 10:38 A.M. of the nursing unit refrigerators located on the House 2 unit revealed brownish food stain in butter dish, dried brownish food splatter along the inside…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-25 · 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
Based on interviews, observations, record review, and policy review the facility failed to ensure Resident #84's call light functioned in a manner to ensure timely service. This affected one resident (Resident #84) of twelve residents reviewed for accommodation of needs. The census was 118. Findings included: Review of the medical record for Resident #84 revealed an admission date of 12/11/23. Diagnoses included encephalopathy, hypertension, heart failure, anxiety and type two diabetes mellitus. Interview and observation on 01/22/24 from 12:54 P.M. through 2:10 P.M. with Resident #84 revealed she was lying in her bed with her legs bent and moving up and down, eyes opened only when spoken to and with a grimace on her face. When asked about if she was in pain, Resident #84 responded yes and asked for help. Call light was turned on at 12:56 P.M. At 1:19 P.M. this surveyor stepped outside the resident room to check to see if the call light system was functioning. The light above the door was lit up. Resident #84's room was located at the end of the hallway. It was the last room of eight…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-25 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure accurate advanced directives were in place for Resident #110. This affected one resident (Resident #110) of 25 residents reviewed for advanced directives. Findings include: Record review for Resident #110 revealed an admission date of 11/09/23. Diagnosis included surgical aftercare following surgery on the digestive system, muscle weakness, cognitive communication deficit, moderate protein calorie malnutrition, hypertensive heart and chronic kidney disease with heart failure. Resident #110 was admitted to hospice services on 12/22/23. Record review of the Significant Change Minimum Data Set (MDS) dated [DATE] revealed Resident #110 was severely cognitively impaired. Resident #110 required assistants with activities of daily living. Resident #110 had medically complex conditions and had a condition or chronic disease that may result in life expectancy of less than six months. Record review of the physician order dated 11/09/23 in the Electronic…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-25 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to maintain clean and sanitary floors in a resident's room. This affected two residents (#7 and #32) of five residents reviewed for environment. The facility census was 118. Findings include: Observation on 01/22/24 at 10:34 A.M. of Resident #7 and #32's floor revealed under the sink a large dark stains that appeared like dirt and also along the edge of the molding. Follow-up observation on 01/24/24 at 11:17 A.M. of Resident #7 and #32's floor revealed the large black dirt like stain on still on the floor under sink. Observed Resident #32 and a visitor and interview at this time the visitor stated the sink had a leak a while ago, but it was fixed but after the stain came. Resident #32's visitor then stated he wondered if it was mold. Interview on 01/24/24 at 11:27 A.M. with Housekeeping Supervisor (HS) #393 revealed the housekeeping staff cleaned residents' rooms and the common areas daily. Observation on 01/24/24 at 11:30 A.M. with HS #393 of Resident #7 and #32's room floor revealed the large black stain under…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-25 · 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, and review of the facility policy, the facility failed to investigate and report an allegation of missing money from Resident #2's purse. This affected one resident (Resident #2) of one resident reviewed for abuse, neglect, and misappropriation. Findings include: Record review for Resident #2 revealed an admission date of 12/18/16. Diagnosis included muscle weakness and need for assistants with personal care. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #2 was cognitively intact. Resident #2 had an impairment to one side of the upper extremity and used a wheelchair. Interview on 01/22/24 at 10:42 A.M. with Resident #2 revealed a few weeks ago she had $31.00 missing from her purse. Resident #2 revealed the administrator and social worker said there was nothing they could do about it and her money had to be in a locked box. Resident #2 revealed they provided her with a locked box. Observation revealed Resident #2 had a grey locked box in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-25 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure Minimum Data Set (MDS) assessments were accurate related to nutrition for Resident #8 and #99. This affected two residents (Resident #8 and #99) of 28 residents reviewed for comprehensive assessments. Findings include: 1. Review of the medical record for Resident #99 revealed an admission date of 10/05/22. Diagnoses included dementia with agitation, muscle weakness, dysphagia, and protein-calorie malnutrition. Review of the quarterly MDS assessment dated [DATE] revealed the resident had severely impaired cognition and had received tube feedings while as a resident. Further review of Resident #99's medical record revealed no documentation the resident had received tube feedings. Interview on 01/24/24 at 2:33 P.M. with Registered Dietitian (RD) #701 stated Resident #99 had never received tube feedings. Interview on 01/25/24 at 9:11 A.M. with MDS Nurse #311 verified she marked in error that Resident #99 received tube feedings on the MDS assessment.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-25 · tag F0646 — isolatedNotify the appropriate authorities when residents with MD or ID services has a significant change in condition.
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 the appropriate state agency (The Ohio Department of Mental Health and Addiction Services) was notified of significant change in a residents Pre-admission Screen (PASRR). This affected one (Resident #49) of two residents reviewed for PASRR status. The facility census was 118. Findings include: Review of the medical record for Resident #49 revealed an admission date of 08/11/20. Diagnoses included but were not limited to schizophrenia, bipolar disorder, anxiety disorder, major depressive order, morbid obesity, rheumatoid arthritis, systemic lupus, and non-Hodgkin's lymphoma. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #49 was cognitively intact and required partial/moderate assistance for bathing and dressing, limited assistance of one for toileting, and supervision for bed mobility, transfer, and personal hygiene. No behaviors were noted. Review of section D question one 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 · D2024-01-25 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of the medical record for Resident #38 revealed an admission date of 05/13/22. Diagnoses included schizoaffective disorder, bipolar, type II diabetes, and Alzheimer's dementia. Review of the quarterly Minimum Set (MDS) assessment dated [DATE] for Resident #38 revealed she had intact cognition and required partial to moderate assistance with showers. Review of the plan of care dated 01/03/24 revealed the resident has potential for declines in activities of daily living (ADL) and self-care related to Alzheimer's and schizophrenia. Intervention included offering and encouraging showers twice weekly. Review of the shower documentation for January revealed Resident #38 received a shower on 01/01/24, 01/04/24, 01/15/24 and 01/18/24, on 01/08/24 and 01/11/24 the shower was documented NA, meaning not applicable the shower did not occur, and on 01/22/24 the resident refused her shower. There was no documented evidence that Resident #38 received a shower from 01/05/24 through 01/14/24. Interview on 01/22/23 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 · Dcited before2024-01-25 · 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 observation, interview, record review and review of the facility policy, the facility failed to ensure Resident #2 was safely positioned while in bed, in a manner to prevent the resident from falling out of bed during personal care provided by staff. This affected one resident (Resident #2) of three residents reviewed for falls. The facility census was 118. Findings include: Record review for Resident #2 revealed an admission date of 12/18/16. Diagnosis included muscle weakness, need for assistants with personal care, chronic pain syndrome, and morbid severe obesity. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 required extensive assistants of two staff for bed mobility. Review of the most recent Quarterly MDS dated [DATE] revealed Resident #2 was cognitively intact. Resident #2 had an impairment to one side of the upper extremity and used a wheelchair. Resident #2 was always incontinent of bowel and bladder. Resident #2 was dependent for toileting and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 23 citations
- Potential for harm · D2024-01-25 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure pharmacy recommendations were addressed by the physician in a timely manner. This affected two residents (Residents #49 and Resident #50) of five residents reviewed for unnecessary medications. The facility census was 118. Findings include: 1. Resident #50's medical record revealed an admission date of 08/25/20 with diagnosis including: traumatic brain injury, hemiplegia affecting left dominant side, dementia with mood disorder, and anxiety disorder. Resident #50 was receiving anti-psychotic medication and had behavioral symptoms such as yelling out, outbursts and exit seeking. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/14/24, revealed the resident had severe impaired cognition, and felt depressed. Review of the monthly pharmacy recommendations to the attending physician dated 12/12/23, revealed a recommendation for a gradual dose reduction of Tramadol (opioid pain medication). The record revealed the physician 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.
- Potential for harm · D2024-01-25 · 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 record review and interview the facility failed to ensure a stop date was added for Resident #99's as needed psychotropic medication, and failed to ensure behavior monitoring was completed for Resident #36 while receiving psychotropic medications. This affected two residents (#36 and #99) of five residents reviewed for unnecessary medications. Findings include: 1. Review of the medical record for Resident #99 revealed an admission date of 10/05/23. Diagnoses included dementia with agitation, dementia with mood disturbance, insomnia, and depression. Review of the Physician orders for January 2024 revealed an active order for Lorazepam (anti-anxiety medication) tablet 0.5 milligrams (mg) to give one tablet by mouth as needed (PRN) for anxiety/restlessness related to dementia with mood disturbance. May give once daily with a start date of 08/31/23 and no end date. Interview on 01/25/24 at 9:19 A.M. with the Director of Nursing (DON) verified the as needed Lorazepam physician order for Resident #99 did not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-25 · tag F0849 — isolatedArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, closed record review, and review of the facility policy, the facility failed to notify Hospice Services and collaborate continuation of care and treatment after discharge for Resident #120. This affected one resident (Resident #120) of three residents reviewed for notification. The facility census was 118. Findings include: Record review for Resident #120 revealed an admission date of 12/21/23 and a discharge date of 12/26/23. Diagnoses included Alzheimer's disease and hypertensive chronic kidney disease. Record review of the admission assessment dated [DATE] at 6:40 P.M. completed by Registered Nurse (RN) #538 revealed Resident #120 was admitted for Hospice Respite stay. Record review of the care plan dated 12/25/23 revealed Resident #120 had a break in skin integrity. The resident had a skin tear related to fragile skin, decreased intake and was on hospice services. Record review of the physician orders dated 12/25/23 for Resident #120 revealed an order for wound care to the right-hand skin…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-25 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to perform proper hand hygiene during medication administration. This affected two residents (Resident #111 and Resident #97) of four residents observed for medication administration. Findings Include: Review of the medical record for Resident #111 revealed an admission date of 11/10/23. Diagnoses included fracture of lumbar vertebra, schizophrenia, chronic kidney disease and muscle weakness. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #111, dated 12/08/23, revealed the resident had impaired cognition and received antipsychotic. Review of the January physicians order revealed the orders for Amlodipine 10 milligrams (mg) used to treat hypertension, Carvedilol 3.125 mg used to treat hypertension, and Fluphenazine 10 mg an antipsychotic used to treat schizophrenia, Review of the medical record for Resident #97 revealed an admission date of 02/02/24. Diagnoses included Alzheimer's Disease, hypertension, and insomnia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-20 · 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
THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of a self-reported incident, review of an investigation, staff interview, and review of facility initiated corrective action, the facility failed to ensure care and services were provided to prevent a resident elopement. This affected one (#100) of three residents reviewed for elopement. The facility census was 120. Findings include: Review of the medical record for Resident #100 revealed an admission date of 02/09/23. Diagnoses included Alzheimer's disease, psychosis, and paranoid schizophrenia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/01/23, revealed Resident #100 had severely impaired cognition, and was independent for ambulation with the assistance of a wheeled walker. Review of the elopement risk assessments dated 02/09/23, 05/09/23, 08/09/23, and 11/11/23 revealed Resident #100 was at a high risk for elopement. Review of the plan of care dated 02/09/23 revealed Resident #100 was at risk…
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 · Fcited before2021-09-24 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and review of facility food storage and labeling policies the facility failed to ensure foods were labeled and stored appropriately. This affected 99 residents receiving food from the kitchen; two residents (Resident #51 and Resident #94) were ordered nothing-by-mouth. The facility census was 101. Findings include: Observation of the kitchen on 09/20/21 from 9:19 A.M. to 9:47 A.M. with Food Service Director (FSD) #543 revealed in the cooler, there was corned beef that expired on 09/18/21 and in the freezer, there was a bun that was freezer-burned. The tour continued to the facility's two nourishment rooms. House Three's nourishment refrigerator revealed two bags of resident food that were unlabeled and undated. House Two's nourishment refrigerator revealed a container in the freezer labeled with Resident #4's name and dated 08/08/21, an undated and unlabeled bag of [NAME] takeout, a bag of Taco Bell take out dated 09/12/21 with no label and two additional containers that were…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2021-09-24 · tag F0922 — failed to maintain the building's systems — widespreadHave enough backup water supply for essential areas of the nursing home.
What the surveyor found here — the official record, unedited, may be distressing
Based on policy review and staff interview the facility failed to develop an emergency water source policy and procedure with all required information. This had the potential to affect all 101 residents currently residing in the facility. Findings include: Review of the policy entitled Water Service Disruption or Contamination of Water Supply dated 07/22/20 on 09/21/21 at 10:20 A.M. revealed the facility had developed a policy to provide food and water for staff or other persons which will stay during an emergency but had no procedure to verify the water on hand could provide the necessary three days of emergency water per it's policy. Interview with the Assistant Maintenance Director (AMD) #606 verified the finding at the time of the policy review. AMD #606 did an audit of the on hand supply and counted 360 gallons on site. The minimum required for the number of beds and staff for the facility was 518 gallons.
- Potential for harm · Ecited before2021-09-24 · 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 resident interview, observation and staff interview the facility failed to ensure a homelike environment that is free from excessive unnecessary clutter in the common shower room on the 600 unit. This affected one (Resident #40) of twenty five sampled residents and had the potential to affect an additional 25 (Residents #2, #6, #7, #8, #10, #11, #13, #29, #31, #36, #37, #42, #44, #47, #52, #54, #61, #65, #72, #76, #80, #81, #92, #93 and #94) who resided on the 600 unit. The facility census was 101. Findings include: Interview with Resident #40 on 09/20/21 at 10:11 A.M. revealed concerns related to the clutter in the shower room on the 600 unit. Resident #40 stated the shower room was full of junk and it made taking a shower feel cramped and uncomfortable. Observation of the 600 hall shower room revealed the shower room contained the following: - Two wheelchairs (one of which was a large geri chair) - One wheeled walker. - Four wheelchair legs - An unused trash can Approximately 40% to 50% of the shower room was occupied by the above noted items. Infection Preventionist #526…
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 · E2021-09-24 · 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 menu spreadsheet review the facility failed to follow the menus for residents receiving a pureed diet. This affected 11 residents (Residents #4, #5, #8, #23, #53, #56, #70, #73, #83, #89 and #93) receiving a pureed diet. The facility census was 101. Findings include: Review of the menu and spreadsheet corresponding to the lunch meal on 09/21/21 revealed a meal consisting of Italian meat sauce, spaghetti pasta, Italian vegetable blend, garlic bread, peach cream pudding and choice of beverage. An alternate meal of creamy mushroom chicken, glazed carrots and rice pilaf was listed on the spreadsheet. Residents on a pureed diet were to receive a #8-scoop of pureed meat sauce, a #8-scoop of pureed spaghetti, a #8-scoop of pureed Italian vegetables and a #16-scoop of pureed bread. Observation of the lunch meal on 09/21/21 starting at 10:48 A.M. revealed a meal consisting of spaghetti pasta, meat sauce, mixed vegetables, breadstick and a fruit cup as well as alternate food items. There were metal pans containing pureed meat sauce, pureed bread and pureed…
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 · E2021-09-24 · 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 observation and staff interview the facility failed to maintain a clean and well maintained environment. This affected 31 residents (#1, #4, #7, #8, #9, #12, #22, #24, #25, #28, #33, #36, #37, #38, #39, #42, #51, #52, #54, #59, #69, #75, #76, #80, #81, #83, #85, #91, #93, #94 and #95) and had the potential to affect all 101 residents currently residing in the facility. Findings include: An environmental tour was conducted on 09/21/21 between 10:30 A.M. and 11:00 A.M. with Environmental Service Director (ESD) #561 and Assistant Maintenance Director (AMD) #606. The following concerns were observed and verified at the time of observation. 1. The tube feed poles and bases for Residents #51, #69 and #94 were stained significantly with dried tube feed solution. 2. The privacy curtain separating Residents #42 and #80 was significantly stained with an unknown black substance. 3. Residents #33 and #38's room had a significant crack in the window sill. 4. The wall directly beneath the air conditioning in Resident #81's room was crumbled to the point of exposing the bare wall. 5. 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 · Dcited before2021-09-24 · 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, interview and record review the facility failed to administer insulin according to physicians orders. This affected one Resident (#58) of six residents reviewed (#20, #32, #36, #51 and #57) for medication administration. The facility census was 104. Findings include: Review of Resident #58's medical record revealed an admission date of 12/18/16 with diagnoses that included diabetes, long term use of insulin and morbid obesity. Review of Resident #58's Minimum Data Set (MDS) dated [DATE] revealed the resident had intact cognition. Review of Resident #58's care plan dated 08/07/21 revealed the resident was dependant on insulin related to diabetes. Interventions included administer insulin and monitor blood sugars as ordered by the physician. Review of physician orders for September 2021 revealed Resident #58 was to receive 24 units of Humalog (fast acting insulin) with each meal. Observation on 09/20/21 at 12:05 P.M. of medication administration revealed Licensed Practical Nurse (LPN) #602…
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 · D2021-09-24 · 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, staff interview, and review of facility drug storage policy and manufacturer's instructions the facility failed to ensure medications and supplements wee stored according to manufacture guidelines. This had the potential to affected 58 residents (#2, #4, #5, #6, #7, #9, #10, #11, #13, #14, #15, #17, #18, #19, #21, #25, #27, #29, #31, #32, #36, #37, #40, #41, #42, #43, #44, #45, #47, #49, #51, #54, #58, #60, #61, #64, #65, #67, #68, #69, #70, #71, #73, #75, #76, #77, #78, #80, #81, #84, #87, #91, #92, #94, #99, #147, #148 and #149) that resided on the 600, 700 and 800 units. The facility census was 104. Findings include: 1. Observation on 09/22/21 at 8:58 A.M. with Licensed Practical Nurse (LPN) #632 of the 800-unit medication cart revealed one opened box of Culturelle probiotics, used to support digestive balance with an expiration date of November 2020. Interview 09/22/21 at 9:05 A.M. with LPN #632 revealed there were no residents with current orders for probiotics. 2. Observation on 09/22/21 at 9:16 A.M. of the medication room for the 600, 700, and 800 units…
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 · Fcited before2019-09-12 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview the facility failed to implement a Legionella prevention program. This had the potential to affect all 113 residents residing in the facility. Findings include: Review of the facility Water Management Program from the Environment of Care Manual, reviewed 06/26/19, revealed the purpose of the program was to protect the health and safety of residents, visitors, and associates by formulating a water management plan that identified and controlled hazardous conditions that support the growth and spread of bacterial organisms, such as Legionella. Review of the program revealed no evidence the facility implemented the policy and procedures of the water management system. Interview on 09/12/19 at 10:32 A.M. confirmed the facility had not implemented the Water Management Program to assist with Legionella Prevention.
- Potential for harm · E2019-09-12 · tag F0550 — failed to protect resident dignity and rights — patternHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview the facility failed to provide a dignified dining experience for Resident #1, #3, #8, #11, #42, #48, #55, #57, #61, #70, #84, #92, #93, #98 and #106 who ate in the dining room of the memory care unit. This affected 15 of 44 residents who resided on the secured memory care unit. The facility census was 113. Findings include: On 09/19/19 observation of the lunch meal beginning at 11:30 A.M. and the dinner meal beginning at 5:45 P.M. on the secured memory care unit revealed the following: At both meals, residents were provided milk in cardboard cartons, juice cups with aluminum foil lids and desserts on Styrofoam. Some residents received a straw, others had some difficulty trying to drink out of the pointed spout of the carton. Some residents received a straw shoved through the aluminum foil lid of the juice cups. Others had the aluminum foil lids pulled back and were trying to drink out of them. Resident #1, #3, #8, #11, #42, #48, #55, #57, #61, #70, #84, #92, #93, #98 and #106 were observed to receive their meals in the above manner.…
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 · D2019-09-12 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview the facility failed to ensure Resident #59 and Resident #114 received a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) upon skilled services ending. This affected two residents (#59 and #114) of three residents reviewed for liability notices. Findings include: 1. Review of Resident #59's Notice of Medicare Non Coverage (NOMNC) form revealed his skilled services ended 07/09/19. Resident #59 remained in the facility upon skilled services ending. There was no evidence Resident #59 received a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN). Interview on 09/11/19 at 9:03 A.M. with Administrator confirmed Resident #59 did not receive a SNFABN. 2. Review of Resident #114's NOMNC form revealed her skilled services ended 05/02/19. Resident #114 remained in the facility upon skilled services ending. There was no evidence Resident #114 received a SNFABN. Interview on 09/11/19 at 9:03 A.M. with Administrator confirmed Resident #114 did not receive a SNFABN.
- Potential for harm · D2019-09-12 · 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 observation, record review and interview the facility failed to ensure Resident #13 received adaptive equipment to assist her during meals to maintain her highest practicable level of independence with eating. This affected one resident (#13) of four residents reviewed for nutrition. Findings include: Record review revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including hypertension, diabetes mellitus, stage three chronic kidney disease, cognitive communication deficit, and muscle weakness. Resident #13's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed her cognition was severely impaired and she required supervision assistance of one person with eating. Resident #13's active comprehensive care plan for nutritional risk revealed she required adaptive equipment at meals. Interventions on the care plan included a sippy cup (two handled cup), and built up utensils. Observation on 09/11/19 at 11:35 A.M. revealed Resident #13 was eating lunch in her room,…
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 · D2019-09-12 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to develop and implement a comprehensive and individualized activity program to meet the total care and activity interest and needs of Resident #60. This affected one resident (#60) of two residents reviewed for activities. Findings include: Record review revealed Resident #60 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including pressure ulcer of left buttock, left knee and right knee contractures, major depressive disorder and anxiety disorder. Resident #60's annual Activity Evaluation, dated 03/14/19 revealed she finds strength in Baptist religion and her current interests included animals, beauty, events and news, movies, radio, religious studies, sing a longs, and television. Resident #60's frequency of activity preference was two to three times a week in her own room. Resident #60's was identified to be interested in life/activities, had a cooperative attitude, declines invitation, and 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.
- Potential for harm · Dcited before2019-09-12 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview the facility failed to ensure Resident #98's vital signs were monitored and physician guidelines were followed when administering medications. This affected one resident (#98) of five residents reviewed for medications. Findings include: Review of the medical record for Resident #98 revealed an admission date of 07/18/19 with a diagnosis including hypertension. Review of the physician orders revealed an order, dated 08/20/19 for Metoprolol Tartrate 25 milligrams (mg) by mouth twice a day with parameters to hold if systolic blood pressure (SBP) less than 110 or if heart rate was below 60 beats per minutes (bpm) and Amlodipine Besylate 5 mg once daily for hypertension with parameters to hold if SBP is less than 110. Review of the vital sign records revealed from 08/20/19 to 09/02/19 Resident #98's blood pressure and pulse were not recorded twice a day for five of the days. There was no blood pressure or pulse recorded from 09/03/19 to 09/11/19. From 08/20/19 to 09/02/19 there were five times when the resident's pulse was below the 60 bpm guideline…
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 before2019-09-12 · 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 observation, record review and interview the facility failed to ensure Resident #80's fall precautions were in place at all times. This affected one resident (#80) of one resident reviewed for falls. Findings include: Record review revealed Resident #80 was admitted to the facility on [DATE] with diagnoses including unspecified injury of head, contractures of left and right knees, repeated falls, difficulty walking, muscle weakness, and cognitive communication deficit. Review of Resident #80's Event Follow-up and Recommendation Form dated 03/17/19 revealed Resident #80 was found lying on his back in front of his wheelchair in his room. As a result of this fall, staff were not to leave the resident unattended in his room. Resident #80's physician order dated 03/17/19 revealed the resident was not to be left unattended in room when up in the wheelchair. Resident #80's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was severely impaired and the resident required…
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 · D2019-09-12 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure the antibiotic stewardship program was effective to prevent the administration of an antibiotic for Resident #80 after the medication had been discontinued. This affected one resident (#80) of three residents reviewed for infections. Findings include: Record review revealed Resident #80 was admitted to the facility on [DATE] with diagnoses including heart failure, chronic kidney disease and peripheral vascular disease. Review of Resident #80's nurse practitioner note, dated 09/03/19 revealed the resident had a vascular wound infection to his right lateral ankle and was ordered the antibiotic, Keflex 500 milligrams (mg) three times a day for seven days. Review of the handwritten telephone order, dated 09/03/19, confirmed the Keflex was ordered on 09/03/19 for seven days. Review of the order entered into the electronic medication system, dated 09/03/19, revealed a stop date of seven days was not included in the order. Review of Resident #80's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2024-01-25 · tag F0814 — failed to dispose of garbage properly — widespreadDispose of garbage and refuse properly.
What the surveyor found here — the official record, unedited, may be distressing
Based on observations and interview, the facility failed to maintain a clean and sanitary area around the trash compactor. This had the potential to affect all 118 residents in the facility. Findings include: Observation on 01/22/24 at 9:30 A.M. of the outside trash compactor revealed on the ground behind the compactor was a moderate amount of various trash and debris including three trash bags of trash, empty cans, and containers. Interview at this time with Dietary Manager (DM) #361 verified the observations and stated trash pickup was on Mondays and Fridays and the trash area was cleaned weekly by the maintenance department.
- No harm found · C2021-09-24 · tag F0570 — widespreadAssure the security of all personal funds of residents deposited with the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and review of resident accounts and the facility surety bond the facility failed to have a surety bond equal to at least the current total in the residents' funds for protection. This affected 70 of 70 residents whose personal funds were managed by the facility (Residents #1, #2, #3, #4, #5, #6, #7, #9, #11, #12, #14, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #27, #28, #29, #30, #31, #32, #33, #34, #37, #38, #40, #43, #44, #45, #47, #49, #50, #51, #52, #53, #54, #55, #59, #60, #61, #64, #66, #67, #70, #72, #73, #75, #76, #77, #79, #80, #81, #82, #85, #87, #88, #89, #92, #93, #94, #95, #399, #400 and #447). Findings include: Review of the residents funds management services list provided by the facility revealed seventy residents had personal funds accounts handled by the facility. The total in the account was $79,139.18. Review of the current surety bond revealed it was worth $50,000 in protection of the resident accounts. Interview with the Administrator on 09/22/21 at 11:41 A.M. verified the surety bond was not sufficient to cover the amount contained in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2021-09-24 · tag F0572 — widespreadGive residents a notice of rights, rules, services and charges.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and resident and staff interview the facility failed to ensure residents were informed of their rights on an ongoing basis. This had the potential to affect all 101 residents currently residing in the facility. Findings include: Completion of the resident council portion of the annual survey on 09/22/21 between 3:00 P.M. and 3:25 P.M. with Residents #58, #67, #84 and #347 revealed there was no ongoing review of residents rights during the resident council meeting or in any other fashion at the facility. Review of the residents council meeting minutes from August 2020 through August 2021 revealed no evidence that residents rights were reviewed during the resident council meeting. Interview with Activity Director #700 on 09/22/21 at 3:30 P.M. verified residents rights were not reviewed during resident council meetings and she was unaware of any other mechanisms in place at the facility to review residents rights on an ongoing basis.
“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 LIFE CARE CENTERS OF AMERICA — 194 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 | 4 of 5 | 3.4 | +0.6 vs chain |
| Health inspection | 3 of 5 | 2.8 | +0.2 vs chain |
| Staffing | 4 of 5 | 3.3 | +0.7 vs chain |
| Quality measures | 5 of 5 | 4.5 | +0.5 vs chain |
The other 193 homes this chain runs (chain average 3.4★, per CMS)
Showing 40 of 193; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| DEVELOPERS INVESTMENT COMPANY INC | Organization | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2006 |
| PRESTON, FORREST | Individual | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 08/31/2000 |
| GRAEFNITZ, SHERRI | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 07/13/2015 |
| LEHMKUHL, STACI | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/26/2025 |
| LONG, ZOFIA | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 03/15/2004 |
| HENRY, TERRY | Individual | CORPORATE DIRECTOR | since 08/16/1999 |
| LAY, LISA | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 02/09/2018 |
| SWANKER, RICHARD | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 01/01/2022 |
| CROSS, CINDY | Individual | CORPORATE OFFICER | since 04/21/1994 |
| THURMOND, JOAN | Individual | CORPORATE OFFICER | since 09/22/2000 |
| LIFE CARE CENTERS OF AMERICA, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/01/1988 |
| MEDINA OPERATIONS, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/27/1988 |
| FLETCHER, TODD | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 12/13/2024 |
| GOYAL, YATISH | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/25/2025 |
| PRESTON, AUBREY | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 12/13/2024 |
| ZIEGLER, JAMES | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 12/13/2024 |
CMS files one row per role, so the 27 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
3 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.
About 72% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $2.1M paid to related parties — landlords or management companies under common ownership — equal to about 16% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OH
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Ohio Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 365085. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-01-25, 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.