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Royal Oak Nursing & Rehab Ctr

6973 Pearl Rd, Middleburg Heights, OH 44130 · For profit - Corporation · 99 certified beds · (440) 884-9191 Medicare & Medicaid certified

Call the home — (440) 884-9191 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Resident-funds citations (F0569, F0570)1 actual-harm citation1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)$8,970 in federal fines
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has citations for mishandling residents’ money or property (F0569, F0570)
  • it has 1 actual-harm citation
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $8,970 in federal fines (most recent 2024-09-16)
  • its payroll-based staffing rating is low (2/5)
  • its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions

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

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

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

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
6879A Southland Dr · (440) 771-1160 · Call to confirm hours
Pharmacy
7003 Pearl Rd · (440) 253-8030 · Call to confirm hours
Grocery
Marc's0.3 mi
6849 Southland Dr · (440) 884-4171 · Call to confirm hours
Park
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 4 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
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 increased5.3%5.3%15.4%typical for the state — see note marked double-dagger below the table
Long-stay residents who lose too much weight7.2%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 infection0.4%0.4%2.0%typical for the state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms15.2%30.1%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury4.1%3.2%3.3%worse
Long-stay residents whose ability to walk worsened2.9%6.1%16.1%better than state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication22.9%25.5%18.9%worse
Long-stay residents given the seasonal flu vaccine96.9%94.5%95.3%typical
Long-stay residents with pressure ulcers6.8%3.4%4.7%worse
Long-stay residents with worsening bladder/bowel control37.2%21.4%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table13.6%8.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine79.5%75.6%79.4%typical
Short-stay residents rehospitalized after admission23.1%24.9%22.6%typical
Short-stay residents with an outpatient ER visit14.2%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.

49.7% 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 32 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

49.7%U.S. median 51.5%
Got home and stayed home
12.5%U.S. median 10.7%
Went back to hospital
0.24U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.06hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.24 therapist hours per resident per day in 2026Q1 — more than 33% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 22% 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 SNF49.7%CMS range 36.0–66.151.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.5%CMS range 8.0–19.110.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final 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 worsened5.9%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.021.02Oct 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

0.49
RN hours/ resident / day
0.75
LPN hours/ resident / day
2.07
Aide hours/ resident / day
3.31
Total nurse hours/ resident / day
0.48
RN hoursweekends
52.1%
Total nursing turnover
62.5%
RN turnover

How full it usually is: this home is certified for 99 beds and averages 59.4 residents a day — about 60% occupied, or roughly 40 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.31 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.49 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.07 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.13 hrs/resident/day on weekends vs 3.39 on weekdays — 8% thinner on weekends. RN hours go from 0.50 to 0.48 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 52% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

2
deficiencies at the latest standard inspection (2024-03-28)
8
at the previous standard inspection (2022-02-10)

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.

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

Inspection deficiencies

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

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.

21 citations, most serious first. The 12 most serious are shown; the remaining 9 are one tap away and print in full.

  • Actual harm · G2024-09-16 · 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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, manufacturer medication information, and interview the facility failed to ensure Resident #69 was free from significant medication error. Actual harm occurred on 07/29/24 when Resident #69 required evaluation and treatment in the emergency room due to a significant medication error of the resident's Topiramate (anti-epileptic/seizure medication). The resident had been administered, per the nurse practitioner, greater than three times the recommended dose of the medication (ordered 100 mg twice a day and received 625 mg twice a day) from 07/24/24 until 07/29/24 when the error was discovered. This affected one resident (#69) of five residents reviewed for medication administration. Findings include: Review of Resident #69's admission orders provided by the family per the Director of Nursing (DON) revealed a hospital After Visit Summary report dated 09/25/23. The…

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

    Pharmacy Service Deficiencies · Past Non-Compliance
  • Actual harm · G2022-02-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and policy review the facility failed to ensure equipment was maintained and in good working condition to prevent a fall with injury for Resident #13. This affected one resident, Resident #13, of two residents reviewed for falls. The facility census was 78. Actual harm occurred on 01/28/21 when Resident #13 sustained a fall resulting in a neck fracture while being assisted by one State Tested Nurse Assistant (STNA) during a shower in a shower bed. Findings include: Review of Resident #13's medical record revealed an admission date of 10/01/13 with diagnoses including dementia without behavioral disturbance, major depressive disorder, hypertension, contracture, cerebral infarction, and hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side. Review of the plan of care dated 10/08/19 revealed Resident #13 required assistance for activities of daily living (ADL) related to cognitive impairment, hemiparesis immobility…

    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 · D2025-08-07 · 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, interview, record review and facility policy review, the facility failed to ensure Resident #43's wound treatment was performed as ordered by the physician. This affected one resident (#43) out of three residents reviewed for wound care. The facility census was 77.Findings include:A review of Resident #43's clinical record revealed an admission date of 07/14/25 with diagnoses including high blood pressure, heart arrhythmias, heart failure with a cardiac pacemaker, hypothyroidism, osteoarthritis, atherosclerotic heart disease, and high cholesterol.A review of Resident #43's wound assessment dated [DATE] indicated the left shin wound measured 0.80 centimeters (cm) long by 2.40 cm wide by 0.1 cm deep. The wound was draining a slight amount of serosanguinous fluid with attached wound edges and intact surrounding tissue. The wound was classified as a skin tear.A review of Resident #43's physician orders revealed an order dated 08/02/25 to perform the left shin wound treatment every Tuesday,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-07 · 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, interview, and facility policy review, the facility failed to ensure enhanced barrier precautions (EBP) were implemented during Resident #22's incontinence and wound care care and Resident #43's wound care. This affected two residents (#22 and #43) of three residents reviewed for EBP. The facility identified 16 residents who required EBP. The facility census was 77.Findings include: 1. A review of Resident #22's clinical record revealed an admission date of 02/11/25 with diagnoses including fracture of the right patella and upper end of humerus, atherosclerotic heart disease, pulmonary hypertension, morbid obesity, anxiety, gastroesophageal reflux disease, high blood pressure, diverticulosis, cardiomegaly, kidney stones with hypertensive kidney failure, benign prostatic hyperplasia, encephalopathy, and obstructive reflex uropathy.A review of Resident #22's physician's orders revealed an order dated 03/11/25 for gloves and gown to be worn when providing dressing,…

    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 · D2024-10-23 · 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, medical record review, and policy review, the facility failed to notify the resident's emergency contact regarding a change in condition. This affected one resident (Resident #100) of three residents reviewed for a change in condition. The facility census was 69. Findings Include: Medical record review revealed Resident #100 was admitted to the facility on [DATE] for skilled therapy after having a hip replacement. Resident #100 was discharged home on [DATE]. Admitting diagnoses include diabetes, high blood pressure, heart disease, congestive heart failure, and osteoporosis. Review of the physician's orders for Resident #100 revealed the resident was taking Eliquis (an anticoagulant) 5 milligrams (mg) twice a day for blood clot prevention. Review of the admission Minimum Data Set (MDS) 3.0 comprehensive assessment for Resident #100, dated 10/14/24, revealed the resident was cognitively intact, was in need of supervision for toileting, and was receiving speech therapy, occupational therapy, 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-28 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review the facility failed to honor Resident #72's preferences for showers. This affected one resident (#72) of two residents reviewed for showers. The facility census was 67. Findings include: Review of the medical record for Resident #72 revealed she was admitted on [DATE] with diagnoses including hypertension (high blood pressure), diabetes mellitus, and muscle weakness. Review of the undated shower schedule revealed Resident #72 received her showers on Wednesdays and Saturdays from 3:00 P.M. to 11:00 P.M. Review of the shower sheet dated 03/09/24 revealed Resident #72 refused her shower on afternoons and wanted her showers in the mornings. Review of the nursing progress note dated 03/12/24 revealed Resident #72 wanted to change her shower times from the evenings to the mornings. Interview on 03/25/24 at 9:44 A.M. with Resident #72 revealed she wanted her showers earlier in the day. She stated she had asked the facility staff, and they told her she had 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-28 · 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 interview, medical record review, and facility policy review, the facility failed to document weekly weights in the medical record for Resident #9. This affected one resident (#9) of four residents reviewed for nutrition services. The facility census was 67. Findings include: Review of the medical record for Resident #9 revealed an admission date of 08/30/06 with diagnoses including aphasia, right non-dominant side hemiplegia, hypokalemia, and diabetes mellitus. Review of the physician's orders revealed an order dated 02/28/24 Resident #9 was to have weekly weights on Wednesdays. Review the Weight Summary revealed on 02/28/24 Resident #9 weighed 162.4 pounds and on 03/06/24 Resident #9 weighed 147.3 pounds. There were no additional weights recorded for 03/13/24 and 03/20/24. Review of the Treatment Administration Record (TAR) for March 2024 revealed missing weight documentation for 03/13/24 and 03/20/24. Review of the Medical Nutrition and Hydration assessment dated [DATE] revealed Resident #9 had…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2022-02-10 · tag F0801 — widespread
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure the dietary manager completed qualifications in a timely manner. This had the potential to affect all residents. The facility census was 78. Findings include: Review of the key personnel revealed Dietary Manager (DM) #610 as the kitchen director. Interview on 02/08/22 at 11:14 A.M. with DM #610 revealed she had worked for the facility for 16 years, seven as the dietary manager. DM #610 stated she was in the process of obtaining her certification as a dietary manager but had not started the classes. Interview on 02/08/22 at 12:24 P.M. with the Administrator verified DM #610 did not have the required qualifications and the Administrator was going to enroll DM #610 into classes to become a certified dietary manager. Review of the Dietary Director Job description under education included must possess a minimum of a high school diploma, be a graduate of an accredited course of dietetic training approved by the American Dietetic Association or have certifications as a certified dietary manager from an approved…

    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 · F2022-02-10 · tag F0803 — failed to meet residents' dietary needs — widespread
    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 review of the meal sheets, staff interview, resident interview, and review of the facility policy, the facility failed to ensure there were alternative menu choices with variety to meet resident preferences. This affected three residents (#16, #49, and #83) of four residents (#16, #49, #71, and #83) reviewed for food and had the potential to affect all residents. The facility census was 78. Findings include: Review of the medical record for Resident #83 revealed an admission date of 06/03/21 and discharge date of 06/25/21. Diagnoses included morbid obesity, hypertension (HTN), mild protein-calorie malnutrition, and gastro-esophageal reflux disease (GERD). Review of physician orders for June 2021 identified orders for regular diet, regular texture, and regular consistency. Review of the medical record for Resident #16 revealed an admission date of 06/24/19. Diagnoses included HTN, diabetes mellitus (DM), and GERD. Review of physician orders for February 2022 identified orders for regular, no added salt diet, regular texture, and regular consistency. Review of the medical…

    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 · F2022-02-10 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff wore hair nets while in the kitchen and the 100 hall nursing unit refrigerator was maintained in a clean and sanitary manner. This had the potential to affect all residents. The facility census was 78. Findings include: 1. Observation on 02/07/22 at 8:51 A.M. revealed Dietary Aide (DA) #796 scooping cooked ground beef out of a pot and into a steam table pan. DA #796 was not wearing a hairnet. Interview at the time of the observation with DA #796 verified DA #796 was not wearing a hair net. Observation on 02/08/22 at 2:02 P.M. revealed DA #904 washing her hands then retrieving serving utensils to puree food for the dinner meal. DA #904 was not wearing a hairnet. Interview at the time of the observation with DA #904 verified DA #904 was not wearing a hair net. Review of the undated facility policy titled Hair Restraints revealed hair restraints shall be worn by all employees while in the kitchen to cover all hair. 2.…

    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 · F2022-02-10 · tag F0814 — failed to dispose of garbage properly — widespread
    Dispose of garbage and refuse properly.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview, the facility failed to maintain a clean and uncluttered area surrounding the outside dumpster. This had the potential to affect all residents. The facility census was 78. Findings include: Observation on 02/07/22 at 8:56 A.M. with Dietary Aide (DA) #796 of the outside dumpsters revealed garbage bags piled high and a moderate amount of debris and empty cardboard boxes in the snow surrounding the dumpsters. Interview at the time of the observation with DA #796 verified the observations. DA #796 stated the dumpsters always looked like this and the nursing aides threw trash around the dumpsters instead of putting trash inside of them. DA #796 stated the maintenance department was responsible for keeping the dumpster area clean.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-02-10 · 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 record review and staff interview, the facility failed to ensure the resident record contained current and accurate information for Residents #67 and #82. This affected two residents (#67 and #82) of two reviewed for accurate medical records. The facility census was 78. Findings include: 1. Review of the medical record revealed Resident #67 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus with chronic kidney disease, chronic obstructive pulmonary disease, and dysphagia. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #67 was alert with cognitive impairment and required assistance of at least two persons for activities of daily living. Observation on 02/07/22 at 9:06 A.M. revealed no operational call light designated for Resident #67. Review of the progress note dated 02/07/22 at 12:25 A.M. revealed Resident #67's call light was within reach. Review of the progress note dated 02/07/22 at 11:41 A.M. 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
Show the remaining 9 citations
  • Potential for harm · D2022-02-10 · tag F0919 — failed to provide a working call system — isolated
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview the facility failed to ensure it had a functional and accessible call light in place. This affected two (Resident #42 and #67) of two residents reviewed for call light function. The facility census was 78. Findings Include: 1. Review of the medical record revealed Resident #67 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus with chronic kidney disease, chronic obstructive pulmonary disease, and dysphagia. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #67 was alert with cognitive impairment and required assistance of at least two persons for activities of daily living. Observation on 02/07/22 at 9:06 A.M. revealed no operational call light designated for Resident #67. Interview on 02/07/22 at 9:06 A.M. with Resident #67 revealed she had no call light. Interview on 02/07/22 at 9:07 A.M. with Licensed Practical Nurse (LPN) #762 confirmed Resident #67 did not have a call light. LPN…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-02-10 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and policy review the facility failed to ensure Resident #67's and #75's walls were maintained in good repair. This affected two of three residents (#67, #75 and #82) reviewed for environment. The facility census was 78. Findings include: 1. Observation on 02/07/22 at 9:06 A.M. revealed a large significant hole with scrapes, chipped paint, furniture markings, and scratches located on the wall directly behind the headboard of Resident #67's bed. Interview on 02/07/22 at 9:07 A.M. with Licensed Practical Nurse (LPN) #762 revealed the hole had been in the wall for a while and was related to the furniture being moved around in the room. Interview on 02/08/22 at 8:35 A.M. with Maintenance Director (MD) #595 confirmed the hole, scrapes, and chipped paint in Resident #67's room. MD #595 said he was aware of the hole in the wall but had just started his role a few months ago and was trying to catch up on the needs of the facility. 2. Observation on 02/07/22 at 12:13 P.M. revealed a large hole in the wall behind Resident #75's bed. Interview on 02/08/22…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2019-07-11 · tag F0569 — pattern
    Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and review of personal needs accounts, the facility failed to ensure the resident/responsible party was notified within $200.00 of the Medicaid resource limit in order to spend down funds in order to maintain Medicaid status. This affected three Residents (#8, #16 and #67) of 48 Residents with accounts (#3, #4, #6, #7, #10, #11, #12, #14, #15, #17, #19, #20, #21 (x2), #22, #23, #24, #26, #27, #28, #31, #32, #34, #35 (x2), #36, #38, #40, #41, #45, #46, #47, #48, #50, #54, #55, #56, #57 (x2), #61, #63, #64, #65, #71 and #371). The facility census was 66. Findings include: Review of Resident #16's personal needs account revealed she had a current balance of $6053.52 as of 07/08/19. The resident was using Medicaid funds to pay for her stay. Review of the last quarterly statement for the first quarter of 2019 revealed she was above the resource limit since 03/15/19 when she had $4026.00 in her account. Interview with the Administrative Assistant, Accounts Payable and Business Office Manager #21 on 07/08/19 at at 3:29 P.M. indicated it was her first time being in this…

    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 · E2019-07-11 · tag F0570 — pattern
    Assure the security of all personal funds of residents deposited with the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of interview, review of personal needs accounts and surety bond, the facility failed to ensure the surety bond was enough to cover the amount of money in the resident accounts. This affected all 48 residents with personal needs accounts (#3, #4, #6, #7, #8, #10, #11, #12, #14, #15, #16, #17, #19, #20, #21 (x2), #22, #23, #24, #26, #27, #28, #31, #32, #34, #35 (x2), #36, #38, #40, #41, #45, #46, #47, #48, #50, #54, #55, #56, #57 (x2), #61, #63, #64, #65, #67, #71 and #371) with a total of $30,705.20 as of 07/08/19. Findings include: Review of the trial balance report with Resident's #3, #4, #6, #7, #8, #10, #11, #12, #14, #15, #16, #17, #19, #20, #21 (x2), #22, #23, #24, #26, #27, #28, #31, #32, #34, #35 (x2), #36, #38, #40, #41, #45, #46, #47, #48, #50, #54, #55, #56, #57 (x2), #61, #63, #64, #65, #67, #71 and #371 current balances revealed the balance of the accounts was $30,705.20. Review of the surety bond dated 10/01/18 and good through 10/01/19 indicated the account was covered for $30,000.00. Interview with the Administrative Assistant, Accounts Payable 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-07-11 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon interview and record review the facility failed to initiate and complete a significant change assessment as required. This affected one (Resident #32) of two resident reviewed with significant changes. Findings include: Review of the medical record for Resident #32 revealed an admission date of 07/06/15. Diagnoses included peripheral vascular disease, heart failure, diabetes, depression and anxiety. Review of the assessments titled Skin Grid Pressure revealed the first assessment was dated 05/24/19 and documented a stage II left buttock pressure area (partial-thickness skin loss with exposed dermis) measuring 1.4 centimeters by 1.3 centimeters by 0.2 centimeters with serosanguineous drainage. Review of the Skin Pressure Grid dated 06/13/19 revealed the resident continued to have an open pressure area on the buttock. Review of the weights revealed on 11/23/18 the resident weighed 157.4 pounds, and on 11/30/18 the resident weighed 154 pounds. On 05/24/19 the resident weighed 140 pounds, creating an…

    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 · D2019-07-11 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately record the medical status of three residents (Resident #70, Resident #72 and Resident #32). This affected three of 28 records reviewed for accurate assessments. The facility census was 66. Findings include: 1. Review of the medical record for Resident #72 revealed he was admitted to the facility on [DATE]. His diagnoses included impulse disorder, unspecified open wound of the scrotum and testes and dementia with behavioral disturbance. Review of the admission Minimum Data Set (MDS) 3.0 assessment with an Assessment Reference Date (ARD) of 06/25/19, section M, indicated conflicting information. The assessment indicated Resident #72 did not have a surgical wound but was receiving surgical wound care. Registered Nurse (RN) #24 was interviewed on 07/10/19 at 2:26 P.M. and was asked if Resident #72 had a surgical wound. RN #24 verified on 07/10/19 at 3:52 P.M. that Resident #72 did have a surgical wound from a biopsy site, and that the MDS data…

    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 · D2019-07-11 · 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, interview, record review and policy review, the facility failed to implement pressure relieving measures and communicate, follow-up and implement podiatry recommendations of Resident #72's pressure ulcers. This affected one Resident (#67) of two residents reviewed for pressure ulcers. Findings include: Review of the medical record revealed Resident #72 was admitted to the facility on [DATE] with diagnoses including impulse control disorder, atrial fibrillation, benign prostatic hypertrophy with lower urinary tract symptoms, hyperlipidemia, open wound of scrotum and testes and dementia with behavioral disturbance. Review of the comprehensive assessment (MDS 3.0) dated 06/25/19 indicated he was severely cognitively impaired and displayed physical abuse, verbal abuse and rejected care during the assessment period. He was identified to have an unstageable pressure ulcer with slough and/or eschar that was present on admission. He was also noted to have an open lesion on the foot. He was…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-07-11 · 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 upon observation, interview and record review, the facility failed to ensure solution used for tuberculin testing was stored according to manufacturer's recommendations. This affected three residents (Residents #70, #71 and #72) admitted to the facility between 06/11/19 and 07/11/19. Findings include: Observation on 07/11/19 at 10:10 A.M. of the medication room on the [NAME] wing with Licensed Practical Nurse (LPN) #26 revealed an open, partially used vial of purified protein derivative solution for tuberculin testing which was undated when opened. The label indicated the pharmacy had dispensed the vial on 01/23/19. Interview on 07/11/19 at 10:11 A.M. with LPN #26 confirmed the vial of tuberculin was undated and she did not know when it had been opened. Review of the Medication Storage policy, dated 06/21/17, revealed the facility was to discard outdated, contaminated, deteriorated medications were to be removed from stock. Review of the manufacturer's package insert for tuberculin purified protein derivative revealed a vial that had been entered and in use for 30 days was 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-07-11 · 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 maintain proper infection control for two residents (Resident #70 and Resident #72). This affected one of one resident on isolation precautions and one of one resident observed for wound dressing changes. The facility census was 66. Findings include: 1. Review of the medical record for Resident #70 revealed he was admitted to the facility on [DATE]. His diagnoses included alcohol dependence with withdrawal delirium, chronic Hepatitis C, dermatitis with Methyl-Resistant Staphylococcus Aureus (MRSA), a bacterial infection. Further review of the medical record for Resident #70 revealed a physician order dated 06/25/19. The order stated the resident was to be on contact isolation (contact precautions). Observation on 07/09/19 at 2:40 P.M., revealed an isolation cart in the hallway near Resident #70's door and a sign on the door with instructions to see nurse before entering the room. During an observation on 07/10/19 at 9:55 A.M., Registered…

    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

“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

$8,970 in federal fines across 1 penalty.

  • $8,970 — penalty dated 2024-09-16

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

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

RatingThis homeChain avg
Overall 3 of 52.4+0.6 vs chain
Health inspection 3 of 52.1+0.9 vs chain
Staffing 2 of 51.8+0.2 vs chain
Quality measures 4 of 54.4-0.4 vs chain
The other 32 homes this chain runs (chain average 2.4★, per CMS)
1 of 5Crystal Care Center Of AshlandAshland, OH 1 of 5Embassy Of East MountainWilkes Barre, PA 1 of 5Embassy Of HearthsideState College, PA 1 of 5Embassy Of SaxonburgSaxonburg, PA 1 of 5Embassy Of ScrantonScranton, PA 1 of 5Embassy Of TunkhannockTunkhannock, PA 1 of 5Heritage Healthcare of LyndhurstLyndhurst, OH 2 of 5Autumnwood Nursing & Rehab CenterRittman, OH 2 of 5Embassy Of CambridgeCambridge, OH 2 of 5Embassy Of Huntingdon ParkHuntingdon, PA 2 of 5Embassy Of WinchesterCanal Winchester, OH 2 of 5Embassy Of Woodland ParkOrbisonia, PA 2 of 5Embassy Of WoodviewColumbus, OH 2 of 5Embassy Of Wyoming ValleyWilkes Barre, PA 2 of 5Forest Hills CenterColumbus, OH 2 of 5Grande OaksOakwood Village, OH 2 of 5Heritage Health Care CenterOakwood Village, OH 2 of 5Longmeadow Care CenterRavenna, OH 3 of 5Clepper ManorSharon, PA 3 of 5Embassy Of Hillsdale ParkHillsdale, PA 3 of 5Embassy Of LoganLogan, OH 3 of 5Embassy Of WillardWillard, OH 3 of 5Hermitage Nursing And RehabilitationHermitage, PA 3 of 5Madison Health CareMadison, OH 3 of 5Oak Hills Nursing CenterLorain, OH 3 of 5Parkside Nursing And Rehabilitation CenterFairfield, OH 3 of 5Pickerington Care And RehabilitationPickerington, OH 3 of 5Seasons Nursing And RehabStow, OH 4 of 5Carlisle Manor Health Care INCCarlisle, OH 4 of 5Embassy Of Park AvenueMeadville, PA 4 of 5Embassy Of SwantonSwanton, OH 5 of 5Embassy Of Valley ViewFrankfort, OH

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
EMBASSY HEALTHCARE HOLDINGS INCOrganizationDIRECT OWNERSHIP INTERESTsince 01/01/2020
2020 GSR DYNASTY LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 01/01/2020
AARON HANDLER FAMILY DYNASTY TRUSTOrganizationINDIRECT OWNERSHIP INTERESTsince 01/01/2020
AH DYNASTY LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 01/01/2020
GEORGE S. REPCHICK 2020 FAMILY DYNASTY TRUSTOrganizationINDIRECT OWNERSHIP INTERESTsince 01/01/2020
HANDLER, AARONIndividualINDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2020
REPCHICK, GEORGEIndividualINDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2020
EMBASSY HEALTHCARE MANAGEMENT INCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2020
HERITAGE EMPLOYMENT SERVICES, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2020
GEBHARD, RICHARDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
MANDAT, THOMASIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025

CMS files one row per role, so the 21 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.

$8.7M
Net patient revenuemost recent cost report
+8.4%
Operating marginrevenue minus expenses
$371K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 21%Medicare 3%Other / private 76%

This home reported $371K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

$300per resident / day
operating cost
$9,125per month
≈ monthly operating cost
$328per 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 365753. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-03-28, 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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