Arbors At Minerva
400 Carolyn Court, Minerva, OH 44657 · For profit - Limited Liability company · 92 certified beds · (330) 868-4104 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- 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
- it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2024
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 3 actual-harm citations
- a high number of inspection citations overall (32) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its payroll-based staffing rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 0.5% | 5.3% | 15.4% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 2.0% | 6.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.2% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.4% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 1.5% | 30.1% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 0.9% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 0.9% | 6.1% | 16.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 19.7% | 25.5% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.0% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 21.6% | 21.4% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 5.5% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 93.4% | 75.6% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 14.6% | 24.9% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 12.4% | 12.9% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 2.73 | 1.73 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.03 | 1.80 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
40.8% 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 52 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 47.6% 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 21 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 0.34 therapist hours per resident per day in 2026Q1 — more than 57% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 11% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 40.8%CMS range 28.9–52.3 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.6%CMS range 5.9–14.5 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 47.6% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 57.1% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 42.9% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.3%CMS range 4.1–11.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.06 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 92 beds and averages 72.9 residents a day — about 79% occupied, or roughly 19 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 3.43 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 1.78 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 2.75 hrs/resident/day on weekends vs 3.70 on weekdays — 26% thinner on weekends — a notable drop. RN hours go from 0.70 to 0.31 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 37% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
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.
32 citations, most serious first. The 13 most serious are shown; the remaining 19 are one tap away and print in full.
- Actual harm · Gcited before2025-01-23 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, emergency medical services (EMS) run report review, death certificate review, policy review, and interview, the facility failed to adequately monitor and provide timely and necessary care and treatment following a change in condition for Resident #1. This affected one (Resident#1) of three reviewed for change in condition. Actual Harm occurred on 12/27/24 at 1:48 A.M. when Resident #1 (who had previously been medicated for nausea/vomiting on 12/26/24 at 3:56 P.M. and 10:38 P.M.) vomited brown-colored emesis and had a decline in her baseline vital signs. The resident's blood pressure was 94/52 millimeters of Mercury (mm/Hg) (normal blood pressure is 120/60 mm/Hg), heart rate was 120 beats per minute (normal is 60-90), temperature was 99.4 Fahrenheit (F), and oxygen saturation was 90% on room air (normal is 92% or higher on room air). Resident #1 complained of aching all over and was given Tylenol (analgesic and fever reducer) 325 milligrams (mg) two tablets. On 12/27/24 at 4:49 A.M.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2023-08-17 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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 facility Self-Reported Incident (SRI) review, medical record review, interview, and facility policy review, the facility failed to ensure residents were free from staff to resident verbal, physical, and sexual abuse. This affected two residents (#35 and #50) of three residents reviewed for abuse. Actual Psychosocial Harm occurred in August 2023 (exact date unknown) to Resident #35 when State Tested Nurse Aide (STNA) #76 told him to scoot your fat a$$ back in the chair, move your fu### legs. Resident #35 was upset. Additionally, on another occasion, date unknown, STNA #76 flung Resident #35's legs into the bed. STNA #76 stretched his legs out and flung them in the bed. Resident #35 told STNA #76 it hurt when she did that. On 08/17/23 Resident #35 remained visibly upset raising his voice when he was describing the actions of STNA #76. Findings include: 1. Review of Resident #35's medical record revealed an admission date of 08/21/20 with admission diagnoses that included impulse disorder, shizoaffective…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2023-04-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to provide adequate assistance, including appropriate lower extremity support during transport of Resident #3 (with hemiparesis/hemiplegia to the right side) in a wheelchair. This affected one resident (Resident #3) of one resident reviewed for a fall with major injury. The facility census was 70. Actual Harm occurred to Resident #3 on 02/20/23 when staff failed to provide adequate lower extremity support to the resident during transport resulting in the resident's leg dragging on the floor and the resident falling from the wheelchair and suffering a right clavicle fracture and proximal humeral fracture. Findings include: Review of the medical record revealed Resident #3 was admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis (weakness) affecting the right side, type 2 diabetes mellitus, chronic embolism and thrombosis, spinal stenosis, osteoporosis, long term use of anticoagulants, major depressive disorder, anxiety disorder,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-02-12 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interviews, the facility failed to ensure transmission-based precautions were followed for Resident #2 and failed to ensure infection control practices were followed during catheter care for Resident #2 and #76. This affected one resident (Residents #2) out of five residents reviewed for transmission-based precautions and two (Residents #2 and #76) out of two residents reviewed for urinary catheters. The facility census was 74.Findings include: 1. Review of the medical record for Resident #14 revealed an admission date of 01/16/26 with diagnoses including sepsis, the presence of right artificial hip joint, need for assistance with personal care. Review of the Discharge summary dated [DATE] from the hospital for Resident #14 revealed she had diagnoses of sepsis and acute on chronic right hip periprosthetic methicillin-resistant staphylococcus aureus (MRSA) wound infection status post revision of total hip arthroplasty and debridement. Review of the care plan dated 01/16/26…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-23 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately 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 record review, policy review, and interview, the facility failed to ensure physician notification occurred with a change in resident condition . This affected one (Resident#1) of three reviewed for change in condition. Findings include: Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included paraplegia, morbid obesity, obstructive hydrocephalus, presence of cerebrospinal fluid drainage device, major depressive disorder, and abnormal posture. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had intact cognition. The resident required physical assistance with activities of daily living. Review of the nursing progress note dated 12/25/24 at 11:30 A.M. revealed the resident received Zofran 4 mg (ordered 11/04/24) by mouth for nausea and vomiting. The administration was listed as effective. Review of the nursing progress note dated 12/26/24 at 8:55 A.M. revealed Resident #1 had frequent episodes of emesis for the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-08-22 · tag F0730 — widespreadObserve each nurse aide's job performance and give regular training.
What the surveyor found here — the official record, unedited, may be distressing
Based on employee file review, staff interview and review of facility policy, the facility failed to ensure State Tested Nursing Assistants (STNAs) had evaluations completed as required. This had the potential to affect all 69 residents residing in the facility. Findings Include: Review of the employee file for State Tested Nursing Assistant (STNA) #274 revealed a hire date of 06/14/23. No annual performance evaluation was found. Review of the employee file for STNA #219 revealed a hire date of 08/17/22. No annual performance evaluation was found. Review of the employee file for STNA #501 revealed a hire date of 02/2024. A 90-day performance evaluation was not found. Interview on 08/22/24 at 12:30 P.M. the facility Administrator verified the evaluations for STNAs #274, STNA #219, and STNA #501 were not completed. Review of the facility policy Performance Appraisals dated 01/01/22 revealed it is the facility policy to evaluate performance of employees at least annually.
- Potential for harm · Fcited before2024-08-22 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, policy and interview, the facility failed to ensure Enhanced Barrier Precautions were in place, indwelling catheters were not dragging on the floor, handwashing met professional standards and tuberculin testing of staff was conducted on hire and annually. This affected Resident's #35 and #51 and had the potential to affect all the residents in the facility. The census was 69. Findings include: 1. Review of Resident #51's medical record revealed an admission date of 08/10/21 with diagnoses including type 2 diabetes, generalized anxiety, cognitive communication disorder, depression, need for assistance with personal care, metabolic encephalopathy, gastroesophageal reflux disease without esophagitis, bipolar disorder, peripheral vascular disease, nicotine dependence, difficulty walking, muscle weakness, fractured femur, obstructive and reflux uropathy, anemia, hypertension, acquired absence of left great toe, acute respiratory failure, anemia, acute embolism and thrombosis of unspecified vein, Parkinson's disease, chronic obstructive pulmonary disease, severe…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-08-22 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard 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, and interview, the facility failed to maintain accurate medical records. This affected five (Resident's #4, #35, #37, #42, and #49) of 19 records reviewed. The census was 69. Findings include: 1. Review of Resident #35's medical record revealed an admission date of 06/22/24 with diagnoses including dysphagia, palliative care, Parkinson's disease, vascular dementia, psychotic disturbance, mood disturbance and anxiety, depression, gastroesophageal reflux disease, weakness, chronic obstructive pulmonary disease, transient cerebral ischemic attack, and hypertension. Interview 08/19/24 at 01:59 P.M. with the resident's wife included her husband does not get out of bed. He doesn't watch television and isn't interested in a whole lot. Activities does not come in and interact with him. Review of the monthly calendar for August 2024 revealed the resident had on the television/movie in room, radio, reminisce, conversation, sermon on in room on television on Sundays. There were up 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.
- Potential for harm · E2024-08-22 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview the facility failed to maintain a clean environment. This affected residents but had the potential to affect all residents residing in the facility. The census was 69. Findings include: On 08/22/24 fro 9:00 A.M. through 9:20 A.M. the following observations were made: 1. Torn wallpaper border was noted between resident rooms, above the medical and storage room on the 100 hall; 300 hall resident rooms as well as above the 300 hall shower room and nurses' station; and 400 hall resident rooms. 2. Black marks from adhesive tape where noted on the ceiling near Resident #20's room and the ceiling above the medical and storage rooms on 100/200 halls. 3. Repaired drywall with unfinished/untextured drywall compound was observed outside the women's bathroom in the front lobby, inside and outside the private dining room, at the 300/400 nurses' station and fire doors, 100/200 hall nurses' station and fire doors. 4. Scraped and damaged drywall from resident beds was noted in the following resident rooms: Resident #7, Resident #20, Resident #33, Resident #42,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-22 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and policy review the facility to maintain privacy during Resident 7's wound care and failed provide a covering to prevent Resident #51's urine from being visible related to his catheter. This affected two residents (#7 and #51) of two residents reviewed for dignity. The facility census was 69. Findings include: 1. Review of the medical record for Resident #7 revealed an admission date of 04/21/17. Diagnoses included spina bifida, paraplegia, and stage three pressure ulcers to the resident's right and left ischial tuberosity. Review of Resident #7's Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact and had two stage three pressure areas. Observation on 08/21/24 at 1:06 P.M. through 1:20 P.M. revealed Licensed Practical Nurse (LPN) #216 and State Tested Nursing Assistant (STNA) #502 entered Resident #7's room to complete wound care. LPN #216 left the resident's door open and pulled the treatment cart up to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-22 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, medical record review, policy review and staff interview the facility failed to ensure the use of a geri chair was appropriate and not considered a restraint. This affected one (Resident #58) of one residents reviewed for restraints. The facility census was 69. Findings include: Observation of Resident #58 throughout the annual survey from 08/19/24 to 08/22/24 revealed the resident seated in a reclined geri chair (comfortable and supportive wheeled seating solution beyond typical wheelchairs and recliners). Review of Resident #58's medical record revealed an admission date of 10/20/23 with diagnosis that included cerebrovascular accident with hemiplegia, prostate cancer and vascular dementia. Review of Resident #58's Minimum Data Set (MDS) 3.0 quarterly assessment with a reference date of 07/24/24 indicated the resident had a severely impaired cognition level and indicated no restraint use in place for the resident. Review of the resident assessments found no evidence of any type of assessment for the use of the geri chair to determine if the resident was able…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-22 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide comprehensive, resident centered activities for dependent residents. This affected two (Resident's #35 and #42) of three residents reviewed for activities. The census was 69. Findings include: 1. Review of Resident #35's medical record revealed an admission date of 06/22/24 with diagnoses including palliative care, Parkinson's disease, vascular dementia, psychotic disturbance, mood disturbance and anxiety, depression, and weakness. Review of an Activities Evaluation dated 06/24/24 revealed he finds strength in faith/religion, gardening/outdoors, movies/television, music/talk radio, pet visits, religious activities, and beauty and barber. Prefers activities in his room in the afternoon and evenings and 1:1 activities. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately impaired for daily decision making, no behaviors, has little interest or pleasure in doing things, feeling…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-22 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide 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, policy and interview, the facility failed to ensure preventative skin care was provided to residents with pressure ulcers. This affected one (Resident #35) of three residents reviewed for pressure ulcers. The census was 69. Findings include: Review of Resident #35's medical record revealed an admission date of 06/22/24 with diagnoses including palliative care, Parkinson's disease, vascular dementia, psychotic disturbance, mood disturbance and anxiety, depression, weakness, chronic obstructive pulmonary disease, transient cerebral ischemic attack, and hypertension. Review of a Braden Scale for Predicting Pressure Sore Risk dated 06/23/24 revealed the resident had no sensory impairment, skin was occasionally moist, walks occasionally, very limited mobility, probably inadequate nutrition, potential problem with shear and friction, and was identified at risk for pressure ulcer development. Review of a resident plan of care for at Risk for Impaired Skin Integrity related 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.
Show the remaining 19 citations
- Potential for harm · D2024-08-22 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, staff interview, and review of the facility policy, the facility failed to adequately monitor enteral nutrition administration for Resident #42 which resulted in a significant weight loss. In addition, the facility did not notify the physician or Registered Dietitian of the significant weight loss in a timely manner. This affected one resident (#42) of one identified by the facility as receiving enteral nutrition. The facility census was 69. Findings include: Review of the medical record for Resident #42 revealed an admission date of 09/05/19 with diagnoses including traumatic brain injury, severe protein-calorie malnutrition, gastrostomy status, dysphagia, persistent vegetative state, aphasia, and tracheostomy status. Review of the physician's orders for June 2024 identified orders for Nutren 2.0 at 50 milliliters (ml) per hour for 24 hours and may substitute Jevity 1.5 if Nutren is unavailable (ordered 05/23/24). The order did not specify an administration rate for the substitution of Jevity 1.5. Review of the Medication Administration Record (MAR)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-22 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, the facility failed to label the contents in a tube feeding/enteral nutrition bag. This affected one (Resident #42) of one residents reviewed for tube feeding. The census was 69. Findings include: Review of Resident #42's medical record revealed an admission date of 09/05/19 and readmission date of 04/15/24 with diagnoses including traumatic subarachnoid hemorrhage, severe protein calorie malnutrition, gastrostomy, tracheostomy, seizures, dysphagia, cognitive communication disorder, and persistent vegetative state. Physician orders included a 05/23/24 order for Nutren 2.0 calorie at 50 millimeters (ml) an hour. Review of the 07/16/24 Annual Minimum Data Set (MDS) Assessment revealed the resident was severely impaired for daily decision making and the resident received tube feeding. Observation of Resident #42 on 08/19/24 at 10:00 A.M. revealed the resident had tube feeding infusing at 50 milliliters an hour through a gastrostomy tube. The bag of tube feeding was labeled with the resident's last name and dated 08/19/24. The label did…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-22 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, policy and interview, the facility failed to ensure oxygen tubing was dated when changed. This affected two (Resident's #32 and #35) of two residents reviewed for oxygen therapy. The census was 69. Findings include: 1. Review of Resident #35's medical record revealed admission date of 06/22/24 with diagnoses including dysphagia, palliative care, Parkinson's disease, vascular dementia, psychotic disturbance, mood disturbance and anxiety, depression, chronic obstructive pulmonary disease, transient cerebral ischemic attack, and hypertension. Physician orders included an order dated 06/22/24 for oxygen tubing/filter to be changed every week. An order dated 07/29/24 to run the oxygen at 4.0 liters per minute continuous. Review of the admission Minimum Data Set assessment dated [DATE] included the resident was moderately impaired for daily decision making and he received oxygen. Observation on 08/19/24 at 10:00 A.M. revealed the resident was in bed, His nasal cannula was on the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-22 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, review of pharmacy recommendations, and staff interview, the facility did not ensure pharmacy recommendations were reviewed and addressed by a physician in a timely manner. This affected three residents (#10, #51, and #58) of five reviewed for unnecessary medications. The facility census was 69. Findings include: 1. Review of the medical record for Resident #10 revealed an admission date of 12/11/18 with diagnoses including major depressive disorder, hypertension, type two diabetes mellitus, morbid obesity, congestive heart failure, vitamin D deficiency, personal history of transient ischemic attack and cerebral infarction, and chronic obstructive pulmonary disorder. Review of the physician's orders for August 2024 identified orders for Mirtazapine tablet 15 milligrams (mg) one tablet once daily at bedtime (ordered 11/30/21), Rivaroxaban 20 mg one tablet once daily in the evening (ordered 11/01/22), Diltiazem HCl extended release 12 hour 120 mg one capsule once daily in the morning (ordered 12/08/23), and Vitamin D 1.25 mg (50,000 UT) one capsule once…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-22 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, medical record review, staff interview, and review of the facility policy the facility failed to maintain a medication error rate of less than five percent (%). The medication error rate was calculated to be 7.69% which included two medication errors of 26 medication administration opportunities. This affected one resident (Resident #22) of six residents observed for medication administration. The facility census was 69. Findings include: Review of the medical record for Resident #22 revealed an admission date of 03/29/2024. Diagnoses included chronic obstructive pulmonary disease with acute exacerbation (COPD), myocardial infarction, Coronary artery disease (CAD), and cute respiratory failure with hypoxia. Review of Resident #22 physician orders dated August 2024 revealed an order for Amlodipine Besylate Oral Tablet 5 mg by mouth in the morning for CAD and Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 100-62.5-25 MCG inhale one puff orally in the morning for COPD. Observation of medication administration on 08/20/24 08:42 A.M. revealed 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.
- Potential for harm · Dcited before2024-06-25 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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 medical record review, review of a facility Self-Reported Incident, interviews and policy review, the facility failed to prevent an incident of resident to resident sexual abuse. This affected one resident (Resident #44) of four residents reviewed for abuse. The facility census was 74. Findings Include: Review of the facility self reported incident (SRI) tracking number 248709 dated 06/17/24 at 9:54 A.M. revealed an allegation or suspicion of sexual abuse. Local Law enforcement was contacted , and an officer came out to complete a report, #24-0212. Resident #7 was placed on one to one supervision. The facility investigation was completed on 06/24/24 at 12:35 P.M. with the allegation of sexual abuse being substantiated. An interview on 06/24/24 with State Tested Nurse Aide (STNA) #505 revealed witnessing inappropriate touching between Resident # 7 and Resident #44. STNA #505 indicated that Resident #7 was sitting next to Resident# 44 in the common dining area at approximately 9:51 A.M. on 06/16/24.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-25 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review , review of a facility self-reported incident, policy review and interviews the facility failed to timely report an allegation of resident to resident sexual abuse to the administrator and state survey agency. This affected one resident (Resident #44) of four residents reviewed for abuse. The facility census was 74. Findings Include: Review of the facility self reported incident (SRI) tracking number 248709 dated 06/17/24 at 9:54 A.M. revealed an allegation or suspicion of sexual abuse. Local Law enforcement was contacted , and an officer came out to complete a report, #24-0212. Resident #7 was placed on one to one supervision. The facility investigation was completed on 06/24/24 at 12:35 P.M. with the allegation of sexual abuse being substantiated. An interview on 06/24/24 with State Tested Nurse's Aide (STNA) #505 revealed they witnessed inappropriate touching between Resident #7 and Resident #44. STNA #505 indicated that Resident #7 was sitting next to Resident #44, in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-18 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, medical record review, resident and staff interviews and policy review, the facility failed to ensure wound care was completed as ordered by the physician. This affected two (Residents #35 and #64) of three residents reviewed for wound care. The facility census was 67. Findings include: 1. Review of Resident #35's medical record revealed an admission date of 11/09/23 with diagnoses that included cerebrovascular accident, diabetes mellitus and hypertension. Review of Resident #35's Minimum Data Set (MDS) 3.0 admission assessment with a reference date of 11/30/23 revealed Resident #35 had intact cognition Review of Resident #35's admission wound assessments revealed Resident #35 was admitted to the facility with bilateral stage two pressure ulcers (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough) to the bilateral heels. Review of Resident #35's physician's orders revealed on 12/01/23 wound care orders to clean the bilateral heels with wound cleanser, apply skin prep (protectant barrier), cover with 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.
- Potential for harm · Dcited before2023-10-24 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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
Based on self-reported incident review, record review, policy review and interview the facility failed to ensure residents were free from financial exploitation by staff members. This affected one (Resident #10) of one residents reviewed for misappropriation of resident funds. The facility census was 66. Findings include: Review of Self-Reported Incident (SRI) #239326 revealed on 09/13/23 Resident #10 informed a therapy staff member that he loaned a staff member $100 to purchase school supplies. Further review of the SRI revealed the therapy staff member advised the facility abuse coordinator (Administrator) of the incident at this time. The facility initiated an investigation of the incident. Facility investigation identified State Tested Nurse Aide (STNA) #105 as the staff member who received money from Resident #10. STNA #105 indicated she borrowed $40 from Resident #10 on 08/14/23 and advised the resident she would pay him back. STNA #105 stated she reimbursed Resident #10 on 08/19/23 the full amount of $40. Facility staff attempted interview with Resident #10, but 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.
- Potential for harm · Ecited before2023-08-17 · tag F0609 — failed to report abuse allegations — patternTimely 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 facility Self-Reported Incident (SRI) review, medical record review, interview, and facility policy review, the facility failed to ensure staff immediately reported staff to resident abuse.This affected two residents (#35 and #50) of three residents reviewed for abuse. Findings include: 1. Review of Resident #35's medical record revealed an admission date of 08/21/20 with admission diagnoses that included impulse disorder, shizoaffective disorder, bipolar, anxiety disorder, chronic obstructive pulmonary disease, congestive heart failure, morbid obesity, mood affect disorder and hypertension. Further review of the medical record including the Minimum Data Set (MDS) 3.0 annual assessment with a reference date of 06/15/23 indicated Resident #35 was independent for daily decision making. The resident required extensive assist for bed mobility, transfers, personal hygiene and toileting. Review of the facility SRI #237972 with a created date of 08/10/23 revealed on 08/10/23 the Administrator was notified of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-04-03 · tag F0885 — failed to notify residents/families about COVID-19 — widespreadReport COVID19 data to residents and families.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and facility policy review the facility failed to notify residents, their representatives and families of a single occurrence COVID-19 in the facility. This affected five residents (Residents #15, #26, #41, #47, and #61) of five residents reviewed for infection control with the potential to affect all 70 residents in the facility. The facility census was 70. Findings included: Review of the facility's COVID-19 positive list for the last four weeks revealed Physical Therapist #505 tested positive on 03/02/23 and Dietary Aide # 403 tested positive on 03/14/23. On 03/30/23 at 11:34 A.M. an interview with Registered Nurse (RN) #420 revealed all families were notified the facility would update the facility website if there was any positive cases of COVID-19 in the facility, RN #420 indicated they did not call families individually unless their family member was affected and positive. RN #420 further indicated the facility residents were not notified unless they were 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.
- Potential for harm · Dcited before2023-04-03 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, medical record review, facility policy review and staff interview the facility failed to ensure residents in reclined wheelchairs had physician's orders in place for use and were appropriately assessed to determine appropriate indication for use. This affected one resident (Resident #4) of one resident reviewed for possible physical restraint use. The facility identified no current residents utilizing physical restraints. The facility census was 70. Findings include: Observations of Resident #4 from 03/27/23 to 03/30/23 revealed the resident utilized a reclining tilt in space wheelchair (a wheelchair with a tilt feature permitting the whole chair to tilt 30 to 60 degrees while maintaining knees at a 90 degree angle). Review of Resident #4's medical record revealed an admission date of 08/01/18 with diagnoses that included chronic obstructive pulmonary disease, peripheral vascular disease and hypertension. Review of Resident #4's Minimum Data Set (MDS) 3.0 quarterly assessment with a reference date of 02/27/23 identified no use of any type of physical restraint.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-03 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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 observation, interview, record review, and facility policy review, the facility failed to ensure a behavioral care plan was in place. This affected one (Resident #21) of one resident reviewed for behaviors. The facility census was 70. Findings Include: Review of medical record of Resident #21 revealed an admission date of 02/022/23 and diagnoses included acute and chronic respiratory failure with hypoxia (low blood oxygen), recurrent unspecified major depressive disorder, altered mental status, and cognitive communication deficit. Review of the admission [DATE] Minimum Data Set (MDS) assessment revealed Resident #21 was cognitively intact, required supervision of one person for locomotion, limited assistance of one person for walking and dressing, limited assistance of two persons for bed mobility, and extensive assistance of two persons for transfers. Review of the 02/27/23 progress note revealed Resident #21 was very agitated and was shouting and calling staff names. Review of the 03/06/23 progress…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-04-03 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and staff interview, the facility failed to ensure thorough weekly skin assessments were completed on the open area to the right palm of Resident #39. This affected one resident (Resident #39) of two residents reviewed for non-pressure skin condition. Findings included: Review of the medical record revealed Resident #39 was admitted to the facility on [DATE]. Diagnoses included chronic respiratory failure, persistent vegetative state, COVID-19, cognitive communication deficit, right and left forearm contracture, traumatic brain injury, traumatic subarachnoid hemorrhage, aphasia, epilepsy, pneumonia, deformity of the head, gastrostomy, tracheostomy, and seizures. Review of the physician's orders revealed Resident #39 had an order to cleanse his right palm with normal saline (NS), apply an abdominal dressing, wrap with Kerlix, change daily and as needed dated for 03/20/23. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #39 had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-03 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation,and staff interview the facility failed to ensure bilateral hand splints were applied to the hands of a resident. This affected one resident (Resident #39) of three residents reviewed for mobility. Findings included. Review of the medical record revealed Resident #39 was admitted to the facility on [DATE]. Diagnoses included chronic respiratory failure, persistent vegetative state, COVID-19, cognitive communication deficit, right and left forearm contracture, traumatic brain injury, traumatic subarachnoid hemorrhage, aphasia, epilepsy, pneumonia, deformity of the head, gastrostomy, tracheostomy, and seizures. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #39 had severely impaired cognition and required total assistance with all activities of daily living. Review of the plan of care dated 05/08/20 revealed Resident #39 needed activities of daily living assistance related to a traumatic brain injury, comatose, and requiring total…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-04-03 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and facility policy review the facility failed to maintain a sterile field during tracheostomy care for Resident #39. This affected one resident (Resident #39) of one resident reviewed for tracheostomy care and treatment. Findings included: Review of the medical record revealed Resident #39 was admitted to the facility on [DATE]. Diagnoses included chronic respiratory failure, persistent vegetative state, COVID-19, cognitive communication deficit, right and left forearm contracture, traumatic brain injury, traumatic subarachnoid hemorrhage, aphasia, epilepsy, pneumonia, deformity of the head, gastrostomy, tracheostomy, and seizures. Review of the physician's orders revealed Resident #39 had an order (dated 07/16/22) for tracheostomy care every shift and as needed. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #39 had severely impaired cognition. The resident required total assist with all activities of daily living…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-03 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services 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 record review and interview, the facility failed to provide ongoing communication with the dialysis center for Resident #7. This affected one resident (Resident #7) of one resident reviewed for dialysis. The facility census was 70. Findings include: Review of the medical record revealed Resident #7 was admitted on [DATE]. Diagnoses included but not limited to end stage renal disease and type 2 diabetes mellitus. Review of the plan of care date dated 02/09/23 revealed Resident #7 required dialysis related to renal failure. Interventions included dialysis on Monday, Wednesday, and Friday, obtain and monitor laboratory/diagnostic work as ordered, and report results to physician and follow up as indicated. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #7 was cognitively intact. Physician orders included dialysis every Monday, Wednesday, and Friday. Review of the medical record for Resident #7 revealed the only dialysis communication was a nutritional profile and pre and post…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-03 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure Resident #60 had appropriate indications for the use of as needed anti-anxiety medication, and non-pharmalogical interventions were attempted before the as needed anti-anxiety medication was administered. This affected one resident (Resident #60) of five residents reviewed for unnecessary medications. Facility census was 70. Findings include: Review of medical record revealed Resident #60 was admitted on [DATE]. Diagnoses included dementia, major depressive disorder, anxiety, and acute kidney failure. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #60 had cognitive impairment. The MDS also revealed Resident #60 received anti-anxiety medication. Plan of care dated 01/09/23 revealed Resident #60 used anti-anxiety medications related to anxiety disorder. Interventions included to administer medications as ordered and monitor for side effects and effectiveness every shift. Targeted behaviors included obsession over bowel 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.
- Potential for harm · D2023-04-03 · tag F0810 — isolatedProvide special eating equipment and utensils for residents who need them and appropriate assistance.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and staff interview revealed the facility failed to provide adaptive feeding utensils for Resident #41 at meal time. This affected one resident (Resident #41) of five residents reviewed for nutrition. Findings included: Review of the medical record revealed Resident #41 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, traumatic brain injury, COVID-19, congestive heart failure, chronic kidney disease, muscle weakness, gastroesophageal reflux disease, major depressive disorder, hypothyroidism, generalized anxiety disorder, dysphagia, iron deficiency anemia, hypertension, transient ischemic attack, feeding difficulties, cognitive communication deficit, aphasia, peripheral vascular disease, non-rheumatic mitral valve disorder, and hypomagnesemia. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #41 had moderately impaired cognation, required supervision with eating. Resident #41 had a weight loss and was not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to ARBORS AT OHIO — 16 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 2.6 | +1.4 vs chain |
| Health inspection | 3 of 5 | 2.3 | +0.7 vs chain |
| Staffing | 2 of 5 | 2.9 | -0.9 vs chain |
| Quality measures | 5 of 5 | 4.2 | +0.8 vs chain |
The other 15 homes this chain runs (chain average 2.6★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| ARK OPCO GROUP, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 07/01/2015 |
| B&Y HEALTHCARE S CORP | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/01/2015 |
| B&Y TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/01/2015 |
| CODY HEALTHCARE S CORP | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/01/2015 |
| CRAIG FLASHNER 2007 TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/01/2015 |
| NORCROSS, ROBERT | Individual | CONTRACTED MANAGING EMPLOYEE | — | since 07/01/2015 |
| ROGERS, STACEY | Individual | CONTRACTED MANAGING EMPLOYEE | — | since 07/01/2015 |
| KIRK, KRISTINE | Individual | W-2 MANAGING EMPLOYEE | — | since 09/01/2016 |
| FLASHNER, CRAIG | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 07/01/2015 |
| PERLSTEIN, YITZCHOK | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 07/01/2015 |
| NOBLE HEALTHCARE MANAGEMENT, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 07/01/2015 |
| PRESTIGE ADMINISTRATIVE SERVICES, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2016 |
CMS files one row per role, so the 14 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted.
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.
This home reported $519K 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
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OH
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Ohio Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 365674. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-12, 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.