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Mentor Hills Post Acute

8200 Mentor Hills Drive, Mentor, OH 44060 · For profit - Limited Liability company · 147 certified beds · (440) 256-1496 Medicare & Medicaid certified

Call the home — (440) 256-1496 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citations on record (F0600, F0602) — most recent Sep 20221 actual-harm citation
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Sep 2022
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • 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-based staffing rating is low (2/5)
  • nursing-staff turnover (62%) runs well above the national median (45%)

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

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

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

Location & what’s nearby

Urgent care / clinic
8140 Norton Pkwy Ste 110 · (440) 255-1115 · Call to confirm hours
Pharmacy
8383 Tyler Blvd · (440) 602-4013 · Call to confirm hours
Grocery
7850 Mentor Ave Great Lakes Mall · (440) 290-7202 · Call to confirm hours
Park
7967 Mentor Ave · (440) 205-0337 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 2 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 2 stars. From monthly CMS archive snapshots.

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

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased6.1%5.3%15.4%worse than state — see note marked double-dagger below the table
Long-stay residents who lose too much weight9.6%6.2%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.2%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.4%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms27.2%30.1%6.5%typical for the state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.3%3.2%3.3%better
Long-stay residents whose ability to walk worsened4.3%6.1%16.1%better than state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication31.6%25.5%18.9%worse
Long-stay residents given the seasonal flu vaccine95.0%94.5%95.3%typical
Long-stay residents with pressure ulcers7.9%3.4%4.7%worse
Long-stay residents with worsening bladder/bowel control24.9%21.4%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table12.3%8.8%17.1%better
Short-stay residents who newly got an antipsychotic medication2.7%1.2%1.4%worse
Short-stay residents given the seasonal flu vaccine47.5%75.6%79.4%worse
Short-stay residents rehospitalized after admission27.9%24.9%22.6%worse
Short-stay residents with an outpatient ER visit17.6%12.9%12.0%worse

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.

50.7% 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 146 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

50.7%U.S. median 51.5%
Got home and stayed home
10.3%U.S. median 10.7%
Went back to hospital
60.0%U.S. median 56.6%
Met the expected recovery
0.24U.S. median 0.31
Therapy hours / resident / day
0.10hours / resident / day
Physical therapy
0.09hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 60.0% 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 30 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 0.24 therapist hours per resident per day in 2026Q1 — more than 32% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 10% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF50.7%CMS range 43.6–59.751.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.3%CMS range 7.3–15.910.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge60.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge66.7%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge63.3%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified97.8%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.7%CMS range 4.9–12.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.941.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.59
RN hours/ resident / day
0.79
LPN hours/ resident / day
2.03
Aide hours/ resident / day
3.40
Total nurse hours/ resident / day
0.37
RN hoursweekends
62.1%
Total nursing turnover
60.0%
RN turnover

How full it usually is: this home is certified for 147 beds and averages 115.0 residents a day — about 78% occupied, or roughly 32 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 3.40 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.59 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.03 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 2.90 hrs/resident/day on weekends vs 3.61 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.68 to 0.37 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 62% is well above 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

3
deficiencies at the latest standard inspection (2025-02-13)
11
at the previous standard inspection (2022-09-19)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

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

35 citations, most serious first. The 11 most serious are shown; the remaining 24 are one tap away and print in full.

  • Actual harm · G2024-07-25 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and facility policy review the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to prevent the development of pressure ulcers, to timely identify new pressure ulcers and to ensure wound care was completed as ordered. This affected two residents (#51 and #79) of four residents reviewed for pressure ulcers. The facility census was 102. Actual Harm occurred on 07/12/24 when Resident #51, who had a history of pressure ulcers, was dependent on staff assistance for most all activities of daily living (ADL) including toileting, hygiene, shower, dressing, transfers, and required partial to moderate assistance with rolling left and right in bed, was found to have an in-house acquired Stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed, slough may be present but does not obscure the depth of tissue loss, may include undermining and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-05 · tag F0774 — isolated
    Help the resident with transportation to and from laboratory services outside of the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and facility policy review, the facility failed to ensure transportation to and from a planned physician appointment for Resident #94. This affected one (Resident #94) of three residents reviewed for transportation assistance. The facility census was 95. Findings include: Review of the medical record revealed Resident #94 was admitted to the facility on [DATE]. Medical diagnoses included malignant neoplasm of right lung, malignant neoplasm of lower right lung, cerebrovascular disease, hypertension, vertigo, hyperlipidemia, anxiety, major depression, gastro esophageal reflux, and abnormal gait. Review of facility document dated 03/25/25, revealed Resident #94 was to have an appointment on 05/02/25 for a CT (computed tomography) of the chest, abdomen, pelvis and a Radiation Oncology appointment to establish a new patient. In addition, on 05/08/25 Resident #94 was to have an appointment with Hematology and Oncology to establish Resident #94 and infusion therapy. 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-02-13 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines and facility policy review, the facility failed to use appropriate transmission-based precautions (TBP) for Resident #84, utilize enhance barrier precautions (EBP) when indicated for Residents #12, #57 and #58 and failed to perform wound care using appropriate infection control practices for Residents #1, #12, #41, and #57. This affected one resident (#84) out of two residents reviewed for TBP, affected three residents (#12, #57 and #58) of six residents reviewed for EBP and affected four residents (#1, #12, #41, and #57) of six residents reviewed for wound care. The facility reported 27 residents (#1, #5, #7, #9, #12, #15, #17, #21, #24, #25, #32, #34, #35, #38, #39, #40, #41, #42, #52, #53, #54, #58, #80, #84, #85, #91 and #302) who had EBP, and 23 residents (#1, #4, #7, #12, #17, #21, #24, #39, #40, #41, #42, #52, #53, #54, #57, #58, #77, #84, #85, #90, #91, #298 and #302) who had wounds.…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-13 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of record, interview and facility policy review, the facility failed to offer/hold quarterly care conference meetings for Resident #21 and/or her representative. This affected one resident (#21) of one resident reviewed for care conferences. The facility census was 96. Findings include: Review of the medical record for Resident #21 revealed an admission date of 03/07/23. Diagnoses included chronic diastolic heart failure, paraplegia, morbid obesity, fibromyalgia, and colostomy. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/01/25, revealed Resident #21 had no memory impairment, was alert and cooperative with normal energy. Review of Resident #21's medical record revealed Interdisciplinary Team (IDT)/Care Conference Notes revealed the only documented evidence of care conferences were on 06/30/23, 03/23/24, and 10/07/24 only. Interview with Resident #21 on 02/10/25 at 8:36 P.M. revealed the resident understood what a care conference was. She denied attending a care plan meeting for a long time. In a follow-up interview with Resident #21 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-23 · tag F0803 — failed to meet residents' dietary needs — isolated
    Ensure 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 review of the menu and spreadsheet, the facility failed to provide the alternate entree at the appropriate portion size. This affected two residents (#24 and #73) of two residents observed to receive the alternate on lunch on 12/18/24 out of 98 residents receiving food from the kitchen (Resident #53 was ordered nothing by mouth). Facility census was 99. Findings include: Review of the menu for Week Two revealed a meal on Wednesday (corresponding to 12/18/24) lunch including cheese ravioli with marinara sauce with a portion size listed as one cup. Review of the diet guide spreadsheet for Day 11 Wednesday (corresponding to 12/18/24) lunch revealed the entrée of cheese ravioli with marinara sauce was to be provided in a one-cup portion for those on a regular diet. Observation on 12/18/24 starting at 11:37 A.M. revealed trayline was set for the lunch meal consisting of chicken, cranberry orange sauce, Brussels sprouts, garden blend rice, dinner roll and an alternate of cheese ravioli in marinara sauce. Observation while Certified Dietary Manager (CDM)…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-25 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and facility policy review the facility failed to ensure resident treatments were completed and/ or documented as ordered. This affected two residents (#58 and #93) out of four residents reviewed treatments. This had the potential to affect 17 residents (#7, #14, #23, #27, #45, #48, #51, #58, #67, #73, #79, #85, #86, #89, #90, #91, and #99) identified by the facility with a treatment order other than barrier cream. The facility census was 102. Findings included: 1. Review of the medical record for Resident #58 revealed an admission date of 05/10/23 with diagnoses including hypertension, anxiety disorder, abnormalities of gait and mobility, and weakness. Review of the care plan dated 07/18/23 revealed Resident #58 had an alteration in skin integrity due to left ankle arterial ulcer. Interventions included check dressing for placement during the provision of routine care and services, document wound status weekly, heel lift suspension boots to be worn as tolerated,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-25 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and facility policy review the facility failed to ensure medical records were maintained in an accurate manner including not documenting the completion of treatments that were not done as ordered. This affected two residents (#58, and #79) out of eight residents medical records reviewed for accuracy. The facility census was 102. Findings include: 1. Review of the medical record for Resident #58 revealed an admission date of 05/10/23 with diagnoses including hypertension, anxiety disorder, abnormalities of gait and mobility, and weakness. Review of the care plan dated 07/18/23 revealed Resident #58 had an alteration in skin integrity due to left ankle arterial ulcer. Interventions included check dressing for placement during the provision of routine care and services, document the wound status weekly, heel lift suspension boots to be worn as tolerated, and treatments per order. Review of the Wound Nurse Practitioner (NP) #692 progress note dated 07/12/24 revealed…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2022-09-19 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview the facility failed to maintain a clean and sanitary environment in the kitchen. This had the potential to affect all 95 residents provided food and beverages from the facility. The facility census was 95. Findings include: Observations on 09/12/22 from 10:10 A.M. to 10:24 A.M. during the initial tour of the kitchen with Dietary Manager #458 revealed the overhead vents above the grill top were greasy and dusty as was the back ledge behind the grill top, the light bulbs above the grill top, and the fire extinguisher nozzles. Inside the microwave was dirty. The sanitizer in one of the sanitizer buckets wasn't at a high enough concentration to be effective. The sanitizer was used for wiping down the counters. The ceiling had areas that were dirty/dusty. These findings were verified by Dietary Manager #458 at the time of the observations. On 09/14/22 at 12:20 P.M. [NAME] #454 used a gloved hand to reach into an open bag and place hamburger buns on the resident's plates. Use of a serving utensil was required. On 09/14/22 at 12:22 P.M. Dietary Manager…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-09-19 · tag F0558 — failed to accommodate residents' needs and preferences — pattern
    Reasonably 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, interview, and record review the facility failed to ensure call light cords were accessible to residents. This affected four residents (Resident's #20, #51, #53, and #74) of 26 residents observed for appropriate call light cord placement. The facility census was 95. Findings include: 1. Review of the medical record for Resident #20 revealed an initial admission date of 11/21/19, and a re-admission date of 01/31/20 with diagnoses including hemiplegia and hemiparesis left non-dominant side, mild cognitive impairment, and dysphagia. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] for Resident #20 revealed the resident had moderate to severe cognitive impairment, required assistance with daily hygiene and oral care related to cerebral vascular accident- left sided hemiparesis. Review of the care plan for Resident #20 indicated the resident required assistance to bathe/shower, and daily hygiene, grooming, dressing, oral care, and eating as needed. The resident also…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-09-19 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor 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 record review, observations, and interviews the facility failed to maintain a sanitary environment. This affected nine (Resident's #9, #19, #27, #32, #36, #67, #68, #69 and #81) of 51 residents residing on the 200/300 hall. The facility also failed to clean wheelchairs. This affected five (Resident's #15, #34, #56, #62 and #84) of 59 residents who utilize wheelchairs. The facility census was 95. Findings Include: 1. Review of the medical record for Resident #9 revealed an admission date of 02/26/22. Diagnoses included adult failure to thrive, diabetes mellitus, and major depressive disorder. Resident # 9 had intact cognition. Review of the medical record for Resident #19 revealed an admission date of 12/27/19. Diagnoses included type two diabetes mellitus with diabetic nephropathy and major depressive disorder. Resident #19 had intact cognition. Review of the medical record for Resident #27 revealed an admission date of 09/16/18. Diagnoses included bipolar disorder and anxiety disorder. Resident # 27 had intact cognition. Review of the medical record for Resident #32…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-09-19 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure 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 record review, observations, and interviews the facility failed to date and or document name on insulin vials/Kwik pens after opening. This affected six (Resident's #9, #18, #19, #36, #37 and #55) of 12 residents who required insulin. The facility census was 95. Findings include: 1. Review of the medical record for Resident #9 revealed an admission date of 02/26/22. Diagnosis included diabetes mellitus. Resident # 9 had intact cognition. Review of the physician orders revealed an order dated 08/21/22 for a Humalog mix 75/25 Kwik pen. 2. Review of the medical record for Resident #18 revealed an admission date of 06/23/21. Diagnosis included type two diabetes mellitus. Resident # 18 had intact cognition. Review of the physician orders revealed an order dated 06/28/22 for glargine insulin solution. 3. Review of the medical record for Resident #19 revealed an admission date of 12/27/19. Diagnoses included type two diabetes mellitus with diabetic nephropathy. Resident #19 had intact cognition. Review of the physician orders revealed an order dated 03/09/22 for glargine insulin…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 24 citations
  • Potential for harm · D2022-09-19 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, interview, and review of shower sheets revealed the facility failed to provide showers/bed baths as preferred. This affected two (Resident's #19 and #80) of five residents reviewed for showers. The facility census was 95. Findings include: 1. Review of the medical record for Resident #19 revealed an admission date of 12/27/19. Diagnoses included type two diabetes mellitus with diabetic nephropathy and major depressive disorder. Resident #19 had intact cognition. Interview on 09/12/22 at 10:20 A.M., Resident #19 stated she does not receive showers on a regular basis. Review of the shower sheets revealed Resident #19 received five showers in August and September 2022. Staff did not provide any documented evidence indicating the resident refused showers. Review of progress notes revealed no documented evidence related to Resident #19 refusing showers. 2. Review of the medical record for Resident #80 revealed an admission date of 06/23/21. Diagnoses included unspecified dementia and altered mental status. Resident #19 had intact cognition. Review of the shower…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-09-19 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    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, review of the facility self-reported incident (SRI), and review of the facility policy the facility failed to ensure staff to resident verbal abuse did not occur. This affected one (Resident #50) of three residents reviewed for abuse. The facility census was 95. Findings include: Review of Resident #50's medical record revealed an admission date of 06/07/19 with diagnoses including idiopathic normal pressure hydrocephalus, dementia with behavioral disturbances, and hemiplegia (weakness) and hemiparesis (paralysis) following cerebral infarction affecting the left non-dominant side. Review of Resident #50's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #50 was cognitively intact and required extensive assistance of one staff for toilet use. Resident #50 was occasionally incontinent of urine and always incontinent of bowel. Resident #50 answered yes when questioned regarding feeling down, depressed, or hopeless, and had trouble falling…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-09-19 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, self-reported incident (SRI) review, and interview the facility failed to secure narcotics to prevent misappropriation. This affected two (Resident's #85 and #291) of 31 residents receiving narcotic medications. The facility census was 95. Findings include: 1. Review of the medical record for Resident #85 revealed an admission date of 02/18/22. Diagnoses included benign neoplasm of peripheral nerves and autonomic nervous system of the face, head, and neck, chronic pain syndrome, and schizoaffective disorder. Resident #85 had intact cognition. Review of the physician orders dated February through April 2022 revealed Resident #85 was ordered oxycodone 5 milligrams (mg) (opioid pain medication) 02/18/22 through 02/20/22. Review of the medication administration record (MAR) February through April 2022 revealed Resident #85 did not receive any oxycodone in March and April 2022. Review of SRI tracking number (#) 220000 dated 04/05/22 revealed facility staff observed two missing narcotic cards holding 30 pills of oxycodone 5 milligrams (mg). Two staff were counting…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-09-19 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to complete a Preadmission Screening and Record Review (PASARR) after a new serious mental disorder diagnosis. This affected one (Resident #51) of three resident records reviewed. The facility census was 95. Findings include: Review of the medical record for Resident #51 revealed an admission date of 08/12/13, and a re-admission date of 02/03/20 with diagnoses including chronic obstructive pulmonary disease, dementia with behavioral disturbance, dysarthria and anarthria, acute and chronic respiratory failure, schizoaffective disorder bipolar type, weakness, anxiety, bipolar disorder, current episode mixed, severe, with psychotic features, and mild cognitive impairment. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] for Resident #51 revealed the resident had moderate cognitive impairment, required limited to extensive assistance to complete activities of daily living related to the resident's physical limitations, impaired…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-09-19 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    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 timely complete an initial Preadmission Screening and Record Review (PASARR) for one (Resident #51) of three resident records reviewed. The facility census was 95. Findings include: Review of the medical record for Resident #51 revealed an admission date of 08/12/13, and a re-admission date of 02/03/20 with diagnoses including chronic obstructive pulmonary disease, dementia with behavioral disturbance, dysarthria and anarthria, acute and chronic respiratory failure, schizoaffective disorder bipolar type, weakness, anxiety, bipolar disorder, current episode mixed, severe, with psychotic features, and mild cognitive impairment. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] for Resident #51 revealed Resident #51 had moderate cognitive impairment, required limited to extensive assistance to complete activities of daily living related to the resident's physical limitations, impaired mobility, and pain. Review of care plan 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-09-19 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review, interview, and policy review the facility failed to assess residents before and after dialysis treatments. This affected one (Resident #36) of seven residents requiring dialysis. The facility census was 95. Findings include: Review of the medical record for Resident #36 revealed an admission date of 10/27/21. Diagnoses included dependence on renal dialysis, falls, and anxiety disorder. Resident #36 had intact cognition. Review of the physician's orders for September 2022 revealed Resident #36 was to receive dialysis every Monday, Wednesday, and Friday. Review of the dialysis communication sheets and progress notes revealed the facility staff did not assess Resident #36 before and after dialysis treatments. Interview on 09/15/22 at 9:44 A.M., the Administrator and Director of Nursing stated facility staff were to assess the resident before and after dialysis and verified the missing documentation. Review of the undated facility policy titled Dialysis Guidelines revealed facility staff were to assess the resident before and after receiving dialysis treatments.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-09-19 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure staff performed adequate hand hygiene during the provision of personal care for residents. This affected two (Resident's #20 and #51) of three residents observed for personal care. The facility census was 95. Findings include: Review of the medical record for Resident #20 revealed an initial admission date of 11/21/19, and a re-admission date of 01/31/20 with diagnoses including hemiplegia and hemiparesis of the left non-dominant side, mild cognitive impairment, and dysphagia. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] for Resident #20 revealed the resident had moderate to severe cognitive impairment, required assistance with daily hygiene and oral care related to cerebral vascular accident- left sided hemiparesis. Review of the care plan for Resident #20 indicated the resident required assistance to bathe/shower, and daily hygiene, grooming, dressing, oral care, and eating as needed. The 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2019-09-13 · tag F0607 — failed to have anti-abuse policies — widespread
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    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 develop and implement a comprehensive abuse policy and procedure to ensure adequate screening systems were in place for all employees prior to hire. The facility failed to implement their abuse policy to ensure all employees were checked against the Nurse Aide Registry for findings concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property, obtain reference checks and ensure a complete criminal background check log was maintained. This affected 62 employees hired between 08/16/18 and 09/13/19 whose personnel files were reviewed. Also, the facility failed to implement their abuse policy for potential abuse for one resident (Resident #68) of one resident reviewed for abuse. This had the potential to affect all 109 residents residing in the facility. Findings included: 1. Review of personnel files of employees hired between 08/16/18 through 09/13/19 revealed the following employees currently employed…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2019-09-13 · tag F0725 — failed to have enough nursing staff — widespread
    Provide 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

    Based on observation, interview and record review, the facility failed to ensure staff were available to meet the needs of residents. This had the potential to affect all 109 residents who resided in the facility. Findings include: 1. The surveyor entered the facility on 09/11/19 at 6:45 A.M. A resident, who identified herself as Resident #20, was sitting in a wheelchair in the lobby. She told the surveyor she was waiting for a bus to pick her up to take her to dialysis and asked the surveyor if she could ask the staff on the 100/200/300 unit to come talk to her about what time the bus was to come. The surveyor walked toward the 100/200/300 unit. The unit was dimly lit and quiet. Staff were noted in the three halls as the surveyor approached. When the surveyor walked toward the large nursing station desk, a staff member, later identified as State Tested Nursing Assistant (STNA) #617, was noted behind the approximately four foot high wall around the desk, sitting in a chair with her head on the desk. The surveyor stated to the staff member, Excuse me, and Good morning, and 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2019-09-13 · tag F0804 — failed to serve food at safe, palatable temperature — widespread
    Ensure 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, record review and interview, the facility failed to ensure food was served at an appetizing temperature and acceptable palatability. This had the potential to affect 106 residents who received meals in the facility. The facility identified Residents #23, #51 and #59 as receiving no food from the kitchen. The facility census was 109. Findings include: An interview conducted on 09/09/19 at 10:42 A.M. with Resident #38 revealed the food sits too long on the delivery cart and was cold whenever it was delivered. An interview was conducted on 09/09/19 at 12:06 P.M. with Resident #373 who revealed she received burnt toast everyday it is on the menu, the eggs were served cold regularly, and the foods that are suppose to be hot are never hot. Resident #373 added the food being cold had caused her to not want to eat, and she knew she had lost weight because of it. An interview conducted on 09/09/19 at 1:45 P.M. with Resident #10 revealed the food served to her in her room was cold when it should be hot, the soup was only lukewarm, and the macaroni and cheese was usually…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2019-09-13 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to maintain a clean and sanitary kitchen area. This had the potential to affect 106 residents who received meals in the facility. The facility identified Resident #23, #51 and #59 as receiving no food from the kitchen. The facility census was 109. Findings include: Observation of the kitchen during the initial tour with Dietary Manager (DM) #610 on 09/09/19 between 9:35 A.M. and 10:20 A.M. revealed three reach-in coolers and one reach-in freezer across from the steam table with food debris and dirt build up around the doors and door seals. Dried spills, splashes and dirt build up was observed on the outside doors of the three reach-in coolers and one reach-in freezer. Dried brown residue and brown dirt build-up was observed around the dispenser nozzles and drainage catchers of the two coffee makers. Food debris, dried spills, and brown dirt build-up were observed on surfaces and in corners and crevices, and on the sides of the two red and five black service carts. The floor in the dry storage room was observed to…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-09-13 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure elevated blood sugar levels were called to the physician as ordered. This affected Resident #10, one of five residents reviewed for unnecessary medications. The facility census was 109. Findings include: Review of the medical record of Resident #10 revealed she was admitted to the facility on [DATE] with diagnosis including diabetes mellitus. She was ordered insulin and blood sugar checks four times a day. Review of the order for insulin doses corresponding to the blood sugar checks, dated 06/28/19, revealed the physician was to be contacted if the resident's blood sugar was less than 60 milligrams per deciliter (mg/dL) or more than 400 mg/dL. Review of the resident's blood sugars for July 2019 revealed her blood sugar on 07/15/19 at 9:00 P.M. was 426 mg/dL, on 07/26/19 at 4:00 P.M. was 487 mg/dL, on 07/31/19 at 4:00 P.M. was 444 mg/dL and at 9:00 P.M. was 435 mg/dL. In August 2019, the resident's blood sugar on 08/24/19 at 9:00 P.M. was 440…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-09-13 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview, the facility failed to report an allegation of neglect for Resident #68 within two hours of the allegation being made. This affected one of two residents reviewed for abuse. The facility census was 109. Findings include: Record review was conducted for Resident #68 who was admitted to the facility on [DATE] with diagnoses including stroke and major depression. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #68 had cognitive impairment and required extensive assistance of two staff for bed mobility, transfers and toileting. An interview was conducted on 09/10/19 at 10:36 A.M. with Resident #97, who was the room mate of Resident #68. During the annual survey's resident screening process Resident #97 was asked if she had ever been abused, neglected or made to feel humiliated or degraded by anyone in the facility. Resident #97 responded with I have not, but I reported something that happened to my room mate. She went on to say 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-09-13 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — the official record, unedited, 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 assessments regarding hospice for Resident #30. This affected one of two residents reviewed for hospice. The facility census was 109. Findings include: Review of the record revealed Resident #30 was admitted to the facility on [DATE] with diagnoses including spinal stenosis, major depression and depression. The resident was sent to the hospital on [DATE] for increase in pain, returning on 06/29/19. A hospice consult was written on 07/02/19, and the resident was admitted to hospice services on 07/05/19. Review of a significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] did not indicate the resident was on hospice. An interview with the assessment nurses, Registered Nurses (RN) #613 and RN #614 on 09/11/19 at 8:33 A.M. verified the resident was receiving hospice services, which should have been marked on the significant change assessment.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-09-13 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and policy review, the facility failed to implement fall interventions per the comprehensive care plan for Resident #72. This affected one resident (Resident #72) of four residents reviewed for falls and accidents. The facility census was 109. Findings include: Record review for Resident #72 revealed an admission date of 10/05/13 and diagnoses including urinary tract infection, diabetes, psychosis, dementia, muscle weakness and multiple sclerosis. Review of fall investigation dated 07/09/19 at 10:43 A.M. revealed Resident #72 had a fall on 07/09/19 as she was trying to get out of bed to use the restroom. She had no injuries, and the bed bolsters were removed from the bed as intervention. Review of fall investigation dated 08/01/19 at 9:21 A.M. revealed on 07/31/19 Resident #72 returned to the facility and had a fall as she became confused with environmental changes. She was provided frequent redirection as intervention. Review of care plan with a revision date of 08/01/19…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-09-13 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide adequate care and treatment to manage diabetes and ensure physician orders were followed related to insulin administration and blood sugar levels. This affected one resident (Resident #57) out of three resident reviewed for blood sugar monitoring. Findings include: Resident #57 was admitted on [DATE] with diagnoses including displaced bimalleolar (ankle) fracture of right lower leg, diabetes mellitus and obesity. A review of resident #57's clinical record indicated a physician order dated 11/08/19 for Humalog insulin (to treat high blood sugar levels), 100 units per milliliter inject 27 units subcutaneously before meals for diabetes mellitus and to hold the administration of the insulin if the blood glucose level was less than 200 milligrams (mg) per deciliter (dL). A review of Resident #57's November 2019 Medication Administration Record (MAR) revealed on 11/10/19 at 8:00 A.M. the blood sugar measured 174 mg/dL, on 11/14/19 at 8:00 A.M. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-09-13 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such 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 and record review, the facility failed to ensure an accurate pain assessment was completed for Resident #30. This affected one of two residents reviewed for pain. The facility census was 109. Findings include: Review of the record revealed Resident #30 was admitted to the facility on [DATE] with diagnoses including spinal stenosis, major depression and depression. Review of her quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she was moderately cognitively impaired and had no symptoms or complaints of pain. Review of a nursing note dated 06/23/19 at 4:30 P.M. revealed the resident told a staff member that she fell yesterday and had told the other nurse. She denied hitting her head or any injury. Review of the medication administration record and computerized nursing notes dated 06/24/19 at 11:18 A.M. indicated the resident was given Tylenol, two tablets, which was ordered for an elevated temperature. The note indicated the resident refused repositioning or ice packs.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-09-13 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    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 #84 was free of significant medication error as he received the incorrect pain medication on medication administration observation. This affected one resident (Resident #84) of eight residents reviewed for medication administration. The facility census was 109. Findings include: Record review for Resident #84 revealed an admission date of 08/09/19 and diagnoses that included lower abdominal pain, osteomyelitis of vertebra lumbar region, chronic kidney disease and osteoarthritis. Review of care plan for Resident #84 dated 08/09/19 revealed he had pain to his back related to osteomyelitis of his thoracic vertebrae. Interventions included offer re-positioning, cold pack to the area, quiet environment, warm liquids to promote comfort and administer pain medications per physician orders. Review of Resident #84's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had intact cognition and was on a scheduled…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-09-13 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure 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 and record review, revealed the facility failed to ensure medications were dated when opened prior to use affecting Residents #36 and #78. This affected one resident (Resident #78) of eight residents reviewed for medication administration and one cart with undated medications for Resident #36 and #78 of four medication carts reviewed for medication storage and labeling. The facility census was 109. Findings include: 1. Observation of medication administration on 09/09/19 at 5:10 P.M. with Licensed Practical Nurse (LPN) #601 revealed she administered Resident #78's Timolol Maleate (glaucoma eye drop medication) 0.5 percent one drop to each eye. The Timolol Maleate bottle was not dated when opened and was not in the manufactures box. The expiration date on the bottle was unable to be located. Interview on 09/09/19 at 5:13 P.M. with LPN #601 verified the Timolol Maleate eye medication was not dated, and she was unsure when the bottle was opened. She verified she did not have the box the medication came in. She verified the eye drops should have been…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-09-13 · tag F0805 — failed to prepare food in a form residents can eat — isolated
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure pureed foods were prepared in the appropriate consistency affecting Resident #55. This affected one resident (Resident #55) out of seven residents with pureed consistency diet texture and had the potential to affect 106 residents receiving meals from the kitchen excluding Resident #23, #51, and #59 as they received nothing by mouth. Finding included: Record review for Resident #55 revealed an admission date of 06/28/18 with diagnoses including cerebrovascular disease, dementia with behavioral disturbances, and aphasia following cerebral aphasia. Review of care plan dated 07/08/18 revealed Resident #55 was at nutritional and hydration risk related to swallowing difficulty related to terminal condition of Alzheimer's. Interventions included report signs and symptoms of diet texture intolerance, and encourage and assist as needed to consume foods and fluids. Review of significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE]…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-09-13 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure Resident #74's indwelling urinary Foley catheter (a flexible tube into the bladder to drain urine) drainage bag and catheter drainage emptying spout was not touching the floor. This affected one resident (Resident #74) of one resident reviewed with an indwelling urinary Foley catheter. This had the potential to affect 15 residents that had urinary Foley catheters at the facility. Findings include: Record review for Resident #74 revealed an admission date of 08/03/19 with diagnoses including urinary tract infections, sepsis, neuromuscular dysfunction of the bladder and multiple sclerosis. Review of care plan dated 08/03/19 for Resident #74 revealed he had an indwelling urinary catheter due to the diagnosis of neurogenic bladder. Review of admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #74 had impaired cognition and required extensive assist of two persons with bed mobility, transfers and toileting. 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · Ccited before2025-02-13 · tag F0585 — failed to handle grievances — widespread
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review, staff interview and facility policy review, the facility failed to ensure a designated Grievance Officer was identified. This had the potential to affect all 96 residents residing in the facility. Findings include: Review of the Grievance Committee list revealed no staff member had been designated as the Grievance Officer. Interview on 02/12/25 at 10:18 A.M. with the Administrator revealed there was no designated Grievance Officer. Review of the facility policy titled Grievances/Complaints, Filing, updated April 2017, revealed the Administrator delegates a Grievance Officer.

    Resident Rights Deficiencies · Deficient, Provider has plan of correction
  • No harm found · Ccited before2019-09-13 · tag F0585 — failed to handle grievances — widespread
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observation and interviews, the facility did not ensure the members of Resident Council (Residents #21, #29, #37, #38, #52, #72, #89, #109 ) were well informed and had access to information on how to file an official grievance or complaint with the facility administration. This had the potential to affect all residents in the facility. The facility census was 109. Findings include: Interviews were conducted on 09/11/19 from 10:30 A.M. to 10:59 A.M. with Residents #21, #29, #37, #38, #52, #72, #89 and #109 as part of the Resident Council meeting with the state surveyor during the annual survey. All the residents at the meeting were alert and oriented and actively participated in the meeting. When the residents were asked if they knew how to file a grievance or official complaint with administration, they unanimously responded they did not know how to file a grievance. When the residents were asked if they had seen or knew where to find information on how to file a grievance, they unanimously responded they did not know where to find that information. Record…

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

    Resident Rights Deficiencies · Deficient, Provider has plan of correction
  • No harm found · C2019-09-13 · tag F0838 — failed to assess facility resources and resident needs — widespread
    Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility did not develop a staffing plan to support the acuity needs on the Facility Assessment according to the regulation requirements. This had the potential to effect all residents living in the facility. The facility census was 109. Findings included: A record review was conducted of the Facility Assessment with the Administrator on 09/13/19 from 10:11 A.M. to 10:19 A.M. In the section titled General Staffing Guidelines for nursing there were no specifications for how many direct care licensed nurses or state tested nursing assistants (STNA) were needed to meet acuity needs of the resident population. That section identified one, full-time Director of Nursing, three full-time unit nurse managers and four other nurses administrative positions were needed but left the remaining information regarding licensed direct care nurses and STNA blank. The Facility Assessment was last updated on 09/06/19. An interview was conducted on 09/13/19 at 10:19 A.M. with the Administrator who verified the section General Staffing Guidelines for nursing 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.

    Administration Deficiencies · Deficient, Provider has plan of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to PACS GROUP — 274 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 52.9+0.1 vs chain
Health inspection 3 of 52.5+0.5 vs chain
Staffing 2 of 52.5-0.5 vs chain
Quality measures 4 of 54.4-0.4 vs chain
The other 273 homes this chain runs (chain average 2.9★, per CMS)
1 of 5Anchor Post AcuteAiken, SC 1 of 5Arbor Post AcuteChico, CA 1 of 5Artesia Palms Care CenterArtesia, CA 1 of 5Arvin Post AcuteArvin, CA 1 of 5Ashland Post AcuteAshland, OR 1 of 5Bakersfield Post AcuteBakersfield, CA 1 of 5Beachwood Post-Acute & RehabSanta Monica, CA 1 of 5Brookshire Post AcuteDenver, CO 1 of 5Brushy Creek Post AcuteGreer, SC 1 of 5Buckeye Care And RehabilitationLancaster, OH 1 of 5Carnegie Park Post AcutePittsburgh, PA 1 of 5Cascade Terrace Post AcutePortland, OR 1 of 5Centennial Post AcuteAnchorage, AK 1 of 5Chandler Creek Post AcuteGreer, SC 1 of 5Chehalem Post AcuteNewberg, OR 1 of 5Country Hills Post AcuteEl Cajon, CA 1 of 5Delhi Post-AcuteCincinnati, OH 1 of 5Dublin Post AcuteDublin, OH 1 of 5Edisto Post AcuteOrangeburg, SC 1 of 5Evan Terrace Post AcuteMcMinnville, OR 1 of 5Forest Acres Post AcuteColumbia, SC 1 of 5Grandview Post AcuteCookeville, TN 1 of 5Great Plains Post AcuteWichita, KS 1 of 5Hemet Hills Post AcuteHemet, CA 1 of 5Highland Hills Post AcutePittsburgh, PA 1 of 5Highline Post AcuteDenver, CO 1 of 5Johns Island Post AcuteJohns Island, SC 1 of 5Karcher Post AcuteNampa, ID 1 of 5Kennedy Care CenterLos Angeles, CA 1 of 5Kern River Transitional CareBakersfield, CA 1 of 5Lakeview Post AcuteFlorissant, MO 1 of 5Marion Valley Post AcuteMarion, OH 1 of 5Mirage Post AcuteLancaster, CA 1 of 5Monroeville Post AcuteMonroeville, PA 1 of 5Napa Post AcuteNapa, CA 1 of 5North Royalton Post AcuteParma, OH 1 of 5Northstar Post AcuteCarson City, NV 1 of 5Overland Park Post AcuteOverland Park, KS 1 of 5Pikes Peak Post AcuteColorado Springs, CO 1 of 5Ridgeway Post AcutePetaluma, CA

Showing 40 of 273; 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 / managerTypeRoleSince
JERGENSEN, JOSHUAIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 12/01/2024
MITCHELL, JOHNIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 12/01/2024
PROVIDENCE GROUP NH, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 12/01/2024
SALOPECK, SARAHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/01/2024
PROVIDENCE ADMINISTRATIVE CONSULTING SERVICES INCOrganizationADP OF THE SNFsince 12/01/2024
SNF OH HOLDCO LLCOrganizationADP OF THE SNFsince 12/01/2024
WELL INTEGRA MASTER JV LLCOrganizationADP OF THE SNFsince 12/01/2024
WELL PM HOLDCO JV LLCOrganizationADP OF THE SNFsince 12/01/2024
WELLTOWER INCOrganizationADP OF THE SNFsince 12/01/2024
WELLTOWER OP, LLCOrganizationADP OF THE SNFsince 12/01/2024
MEHTA, DHARMESHIndividualADP OF THE SNFsince 12/01/2024

CMS files one row per role, so the 14 rows in the source record cover these 11 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.

7 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.

$5.9M
Net patient revenuemost recent cost report
-18.6%
Operating marginrevenue minus expenses
$366K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 24%Medicare 5%Other / private 71%

This home reported $366K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$323per resident / day
operating cost
$9,805per month
≈ monthly operating cost
$272per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in OH

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Ohio Medicaid page.

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

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 365691. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-02-13, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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