Carecore At Minster
24 North Hamilton Street, Minster, OH 45865 · For profit - Corporation · 83 certified beds · (419) 628-2396 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)
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (26% vs 45% nationally) — better care continuity
- it has an abuse, neglect, or exploitation citation (F0600), cited Jul 2025
- it has a citation for mishandling residents’ money or property (F0568)
- it has 2 actual-harm citations
- a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $28,743 in federal fines (most recent 2025-07-21)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
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 | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 3 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 3 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 4.6% | 5.3% | 15.4% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 5.2% | 6.2% | 5.4% | typical |
| 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 | 13.0% | 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 | 3.9% | 3.2% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 10.3% | 6.1% | 16.1% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 31.5% | 25.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.8% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 19.3% | 21.4% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 35.3% | 8.8% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 2.4% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 94.4% | 75.6% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 20.2% | 24.9% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 11.0% | 12.9% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 1.86 | 1.73 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.50 | 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.
56.2% 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 40 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.29 therapist hours per resident per day in 2026Q1 — more than 44% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 6% 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 | 56.2%CMS range 41.9–70.3 | 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 | 10.6%CMS range 6.1–15.4 | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.8%CMS range 2.8–13.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.12 | 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 83 beds and averages 60.6 residents a day — about 73% occupied, or roughly 22 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 4.45 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.50 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.48 is at or above 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 3.93 hrs/resident/day on weekends vs 4.65 on weekdays — 15% thinner on weekends. RN hours go from 0.57 to 0.33 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 26% is below the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
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.
29 citations, most serious first. The 12 most serious are shown; the remaining 17 are one tap away and print in full.
- Actual harm · Gcited before2025-07-21 · 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, staff interview, review of a Facility Reported Incident, review of police report, review of hospital records, and review of policy, the facility failed to ensure a cognitively impaired resident was free from physical abuse by a facility staff member. This resulted in physical harm when Resident #01 was forcefully pushed down on to a bed by Certified Nursing Assistant (CNA) #200 causing physical injuries of bruising, skin impairments and pain. During the incident, Licensed Practical Nurse (LPN) #202 observed and failed to intervene to protect Resident #01 from abuse. This affected one (#01) of three residents reviewed for abuse. The facility census was 55. Findings include:Review of the medical record of Resident #01 revealed an admission date of 11/26/24. Diagnoses include unspecified psychosis, depressive disorder, Alzheimer's disease, and dementia.Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #01 was cognitively impaired and required set-up…
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 before2023-12-04 · 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 medical record review, review of hospital records, and staff and Physician #850 interviews, the facility failed to ensure a newly admitted resident received appropriate diabetes care when the facility staff failed to clarify a resident's diabetes diagnosis and the need for blood sugar monitoring and insulin administration. This resulted in Actual Harm when staff failed to monitor Resident #04's blood sugars and the resident subsequently had a change in condition resulting in hospitalization and a diagnosis of hyperglycemia requiring intravenous (IV) and subcutaneous (SQ) insulin administration and (IV) fluids. Additionally, the facility failed to have blood glucose monitoring and insulin in place for Resident #38, which placed the resident at risk for more than minimal harm. This affected two (Residents #04 and #38) of three residents reviewed for diabetes management. The facility census was 50. Findings include: 1. Review of the medical record of Resident #04 revealed an admission date of 08/17/23.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-09-18 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, review of manufacturer instructions, and policy review, the facility failed to store, prepare, and distribute food in a safe and sanitary manner. This had the potential to affect all residents who receive food from the kitchen. The facility identified one (#10) resident that did not receive food from the kitchen. The facility census was 56.Findings include:1. Observation of the kitchen on 09/15/25 at 7:49 A.M. revealed one of the two hand washing sinks did not have paper towels to dry hands, the two storage shelves under the preparation tables were covered in a greasy debris. Additional observation revealed greasy debris in the cabinet shelf above the preparation table. The findings were confirmed by Dietary [NAME] (DC) #310 at the time of the observation.2. Observation on 09/15/25 at 7:55 A.M. of the of the four flavor cold beverage juice dispenser revealed a sticky dried on substance on all four nozzles. Further observation revealed a sticky dried substance on top of and under the shelf that holds the bottles of concentrate 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 · D2025-09-18 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, observations, staff interviews, and review of the Long- Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure accurate coding on Minimum Data Set (MDS) assessments. This affected one (#50) of five residents reviewed for accidents. The facility census was 56. Findings include:Review of the medical record for Resident #50 revealed an admission date of 09/01/24 with medical diagnoses including convulsions, diabetes mellitus, morbid obesity, and Down syndrome. Review of the medical diagnoses revealed on 08/04/25 Resident #50 was given a diagnosis of a pathological fracture of the right humerus. Review of the medical record for Resident #50 revealed no documentation to support a diagnosis of osteoporosis prior to 08/03/25. Review of the medical record for Resident #50 revealed a discharge Minimum Data Set (MDS) assessment, with Assessment Reference Date (ARD) of 08/16/25, which indicated Resident #50 had moderate cognitive…
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 before2025-09-18 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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 policy review, the facility failed to develop a plan of care to address resident's with a diagnosis of post-traumatic stress disorder. This affected two (#7 and #43) of two residents review for PTSD. The facility census was 56.Findings include:1. Review of medical record for Resident #7 revealed an admission date of 05/30/25 with diagnoses including but not limited to post-traumatic stress disorder (PTSD), major depressive disorder, anxiety disorder, and dementia.Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had moderate cognitive impairment. Resident #7 was assessed with PTSD.Review of Resident #7's care plan dated 05/30/25 revealed no care plan addressing the resident's PTSD.Review of a psychiatric note dated 08/19/25 revealed Resident #7's PTSD listed as a diagnosis but was not addressed.Interview on 09/17/25 at 11:26 A.M. with Certified Nurse Aide (CNA) #345 revealed the CNA did not know what Resident #7's PTSD was related…
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 · D2025-09-18 · 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 medical record review, review of fall investigation reports, and staff interview, the facility failed to ensure care plans were updated with current fall interventions. This affected one (#50) of five reviewed for accidents. The facility census was 56. Findings include:Review of the medical record for Resident #50 revealed an admission date of 09/01/24 with medical diagnoses including convulsions, diabetes mellitus, morbid obesity, and Down syndrome. Review of the medical record for Resident #50 revealed an annual Minimum Data Set (MDS) assessment dated [DATE] which indicated Resident #50 had moderately impaired cognition, was independent with bed mobility, transfers, and ambulation up to 10 feet, and required supervision with ambulation up to 50 and 150 feet. The MDS assessment indicated Resident #50 did not use a wheelchair. The MDS assessment indicated Resident #50 had two or more falls with no injury since readmission on [DATE]. Review of the fall care plan, dated 09/23/24, revealed Resident #50 was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-18 · 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, resident representative interview, staff interview, medical record review, and policy review, the facility failed to assist residents in attending scheduled activities of their preference and on a consistent basis. This affected two (#10 and #9) of three residents sampled for activities. The facility census was 56.Findings include:1. Review of the medical record revealed Resident #10 was admitted on [DATE] with diagnoses of spastic quadriplegic cerebral palsy and aphasia. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #10 revealed the resident was completely dependent for all care and exhibited no rejection of care or behavioral issues. Review of the care plan dated 09/16/25 for Resident #10 revealed the resident was dependent on staff for all activities with interventions to bring the resident to the activity room to be around other residents during activities and to escort the resident to activities they may be interested in. Review of an order dated 05/30/25…
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 before2025-09-18 · 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, resident and staff interview, medical record review, and policy review, the facility failed to ensure orders for dressing changes were completed as ordered. This affected one (#44) of two residents sampled for dressing changes. The facility census was 56.Findings include:Review of the medical record revealed Resident #44 was admitted on [DATE] with diagnoses including unspecified atrial fibrillation and diabetes mellitus with neuropathy.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #44 had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognitive function.Review of the care plan for Resident #44 dated 09/18/25 revealed Resident #44 was at risk for impaired skin integrity due to a left lower extremity contusion and a left posterior ankle blister. Interventions included to provide treatment as ordered.Review of physician orders for Resident #44 revealed an order dated 09/12/25 for a dressing to the left lower leg contusion with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-18 · 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
Based on medical record review, review of a dialysis binder, and staff interview, the facility failed to ensure adequate and appropriate clinical information was provided to and received from a dialysis provider to ensure coordination of care. This affected one (#4) of one residents reviewed for dialysis. The facility census was 56.Findings include:Review of the medical record for Resident #4 revealed an admission date of 07/31/25 with diagnoses including but not limited to end stage renal disease, non-compliance with renal dialysis for other reasons, and dependence on renal dialysis.Review of current physician orders revealed Resident #4 was scheduled for dialysis treatments on Mondays, Wednesdays, and Fridays.Review of a care plan dated 07/31/25 revealed Resident #4 had renal failure related to end stage renal disease and dependence on renal dialysis. Interventions included to auscultate heart and lung sounds, check bruit and thrill (a thrill is a palpable, buzzing sensation or vibration felt on the skin overlying a blood vessel due to turbulent blood flow, while a bruit is 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 · D2025-09-18 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, staff interview, and Medical Director interview, the facility failed to ensure a resident was free from unnecessary medications including duplicate drug therapy. This affected one (#45) of three residents reviewed for antibiotic use. The facility census was 56.Findings include: Review of the medical record for Resident #45 revealed an admission date of 06/13/24 with medical diagnoses including anxiety, anemia, chronic kidney disease stage III, and personal history of urinary tract infection (UTI). Review of the medical record for Resident #45 revealed a quarterly Minimum Data Set (MDS) assessment, dated 09/15/25, that revealed Resident #45 had moderate cognitive impairment and required partial/moderate staff assistance with toilet hygiene, and substantial/maximum staff assistance with bathing, bed mobility, and transfers. The MDS assessment indicated Resident #45 received an antibiotic medication. Review of the medical record for Resident #45 revealed a nurse's notes dated 11/20/24 at 1:20 P.M. which documented the doctor assessed Resident #45,…
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 · D2025-09-18 · tag F0804 — failed to serve food at safe, palatable temperature — isolatedEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, recipe review, and policy review, the facility failed to ensure pureed food was prepared in a manner that preserved flavor and nutrition. This had the potential to affect three (#12, #22, and #56) of three residents identified by the facility as being on a diet with pureed meat. The facility census was 56.Findings include:Observation on 09/15/25 at 9:41 A.M. revealed Dietary [NAME] (DC) #310 prepared country fried steak with a pureed texture. Continued observation revealed DC #310 placed five portions of the country fried steak into the food processor. DC #310 proceeded to add water to puree the meat. DC #310 placed the pureed steak into a container, covered with foil, and placed it in the oven for service.Review of the undated recipe titled, Country Fried Steak with Cream Gravy, revealed pureed food characteristics included puree being smooth without lumps, held its shape on a plate, was soft pudding like consistency, liquid did not separate from the solid and it did not need to be chewed. Further review revealed the procedure for preparation…
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 · D2025-09-18 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, staff interview, physician interview, and policy review, the facility failed to ensure the antibiotic stewardship program was followed per policy. This affected one (#45) of three residents reviewed for antibiotic use. The facility census was 56.Findings include:Review of the medical record for Resident #45 revealed an admission date of 06/13/24 with medical diagnoses including anxiety, anemia, chronic kidney disease stage III, and personal history of urinary tract infection (UTI). Review of the medical record for Resident #45 revealed a quarterly Minimum Data Set (MDS) assessment, dated 09/15/25, that revealed Resident #45 had moderate cognitive impairment and required partial/moderate staff assistance with toilet hygiene, and substantial/maximum staff assistance with bathing, bed mobility, and transfers. The MDS assessment indicated Resident #45 received an antibiotic medication.Review of the medical record for Resident #45 revealed a nurse's notes dated 11/20/24 at 1:20 P.M. which documented the doctor assessed Resident #45, reviewed the chart, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 17 citations
- Potential for harm · E2025-02-18 · tag F0680 — patternEnsure the activities program is directed by a qualified professional.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on employee file review and staff interview, the facility failed to ensure the Activity Director was qualified. This had the potential to affected 28 residents (#1, #2, #3, #4, #5, #7, #12, #14, #16, #18, #20, #25, #26, #28, #29, #31, #33, #34, #35, #36, #37, #39, #41, #46, #47, #48, #52 and #53) who regularly attend activities. The facility census was 53. Findings include: Review of the employee file for Activities Director (AD) #340 revealed a hire date of 07/25/21 to the activity department as a part time activities assistant. Review of application revealed no previous activities experience. No documentation located regarding when AD #340 went full-time or was promoted to Activities Director. Interview on 02/18/25 at 12:59 P.M. with AD #340 revealed she believed she was promoted approximately a year ago to Activities Director and went full-time approximately three months after hire. AD #340 stated she was taking the certification program through a sister facility. AD #340 verified she did not have a certificate for Activities Director. The facility confirmed there were 28…
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 · D2025-01-17 · tag F0568 — isolatedProperly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, review of resident trust accounts, resident interview, staff interview, resident representative interview and review of facility policy, the facility failed to maintain a complete, accurate and accessible accounting of resident trust accounts and further failed to provide quarterly statements to residents for those accounts. This affected three (#1, #2 and #3) of three residents reviewed for personal funds. The facility identified 35 residents who had resident trust accounts. The facility census was 57. Findings include: 1. Review of Resident #1's medical record revealed an admission date of 05/14/24. Diagnoses included epilepsy, anxiety disorder, post-traumatic stress disorder, major depressive disorder, and dementia. Review of the Minimum Data Set (MDS) assessment, dated 12/31/24, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of nine, indicating the resident was moderately cognitively impaired. Review of the care plan, revised 01/17/25, revealed Resident #1 had supports and interventions for pain, communication problems,…
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 before2024-07-23 · 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 record review, staff interview, and policy review, the facility failed to prevent resident to resident abuse. This affected two (Residents #52 and #45) of four reviewed for abuse. The facility census was 63. Findings include: 1. Review of the medical record for Resident #52 revealed an admission date of 07/26/23 with a diagnosis of Alzheimer's disease. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #52 had moderate cognitive impairment, required set-up assistance with eating and personal hygiene, required supervision with oral hygiene. Resident was independent with dressing, bed mobility, transfers, and ambulation. Review of the Care Plan dated 04/09/24 revealed Resident #52 required a secured unit. Review of progress notes revealed on 07/11/24 at 8:17 P.M., Resident #52 was walking towards the nurse's station when a male resident turned and put his arm around her head from behind and shoved a pudding cup into her face. 2. Review of the medical record for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-04-19 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and staff interviews, the facility failed to ensure the laundry room wall was in good repair without missing drywall or black substance on wall and around the window. This had the potential to affect 55 residents who have their laundry washed at the facility, the facility identified three (#20, #21 and #25) residents who do not have their laundry washed by the facility. The facility census was 58. Findings include: Interview on 04/19/24 at 8:50 A.M. with Laundry Aide #123 stated the wall near the folding table in the laundry room had several areas of black substance on the wall below the window, around the window and under the air conditioning (AC) unit which was above the window. Laundry Aide #123 stated the wall had been missing part of the drywall for over one year and there had not been a change in the appearance of the black substance around the window and AC unit. Observation on 04/19/24 at 9:05 A.M. revealed a window and wall near the folding table in the laundry room to be missing part of the drywall under the window, window ledge deteriorated with part…
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 · D2023-12-04 · 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, staff interview and review of information from Medscape, the facility failed to ensure the physician was notified regarding a residents low blood glucose reading. This affected one (#14) of three residents reviewed for notification of change. The facility census was 45. Findings include: Review of medical record for Resident #14 revealed admission date of 08/17/23. Diagnoses included acute kidney failure, sepsis, type two diabetes mellitus with hyperglycemia, and bipolar disorder. The quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had severe cognitive impairment and he required moderate assistance with eating, maximum assistance for bed mobility and dependence for transfers. Review of the physician orders for Resident #14 revealed an order for Lantus (long-acting insulin) 20 units subcutaneously two times daily. Hold medication for a blood sugar of less then 80 and contact physician for further instructions. This was scheduled for 8:00 A.M. and 8:00 P.M. with a start…
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 · D2023-12-04 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and staff interviews, the facility failed to ensure a residents admission physician orders were implemented. This affected one (#11) of three residents reviewed. The facility census was 45. Findings include: Review of medical record for Resident #11 revealed admission date of 12/22/23. Medical diagnoses included dementia without behaviors, chronic pain, non-pressure chronic ulcer, and atrial fibrillation. Review of the transfer admission orders for Resident #11 revealed an order for Milk of Magnesia (laxative) 30 milliliters (ml) every 24 hours as needed. Further review of the physician orders and December 2023 Medication Administration Record (MAR) for Resident #11 revealed no order for Milk of Magnesia. Interview on 12/27/23 at 10:54 A.M. with the Director of Nursing (DON) verified an admission order for Milk of Magnesia 30 ml every 24 hours as needed for Resident #11 was not ordered and not placed on the MAR upon the residents admission. This is a new deficiency based on the post survey revisit for the complaint survey completed on 12/04/23.
- Potential for harm · D2023-12-04 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and review of information from Medscape, the facility failed to ensure insulin was administered as ordered resulting in significant medication errors. This affected one (#14) of three residents reviewed for blood glucose monitoring. The facility census was 45. Findings include: Review of medical record for Resident #14 revealed admission date of 08/17/23. Diagnoses included acute kidney failure, sepsis, type two diabetes mellitus with hyperglycemia, and bipolar disorder. The quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had severe cognitive impairment and he required moderate assistance with eating, maximum assistance for bed mobility and dependence for transfers. Review of the physician orders for Resident #14 revealed an order for Lantus (long-acting insulin) 20 units subcutaneously two times daily. Hold medication for a blood sugar of less then 80 and contact physician for further instructions. This was scheduled for 8:00 A.M. and 8:00 P.M. with a…
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 before2023-01-12 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, and policy review, the facility failed to ensure open food products in the refrigerator and/or freezer were dated after opening. This had the potential to affect 37 out of 39 residents residing in the facility who receive their meals from the kitchen, the facility identified two (#22 and #193) resident who did not receive meals from the kitchen. Facility census was 39. Findings include: Observation on 01/09/23 from 8:30 A.M. to 8:45 A.M. of the kitchen revealed reach-in refrigerator had one package of Canadian ham in Ziploc bag, one ranch dressing tub, and two bowls of food which were not dated. Observations in the walk-in freezer revealed one Ziploc bag of mixed vegetables undated. Observations in the walk-in refrigerator revealed seven pureed meats in individual Styrofoam bowls were undated. Interview on 01/09/23 at 8:43 A.M. with [NAME] #146 verified pureed meat, mixed vegetables, ham, ranch dressing, and bowls were not dated. [NAME] #146 verified food was to be dated when opened. The facility confirmed 37 out of 39 residents residing 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 · E2023-01-12 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop and implement policies and procedures for flu and pneumonia vaccinations.
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 interviews, review of facility policy and review of Centers for Disease Control and Prevention (CDC) Guidelines, the facility failed to offer residents the pneumonia vaccinations per CDC Guidelines. This affected four (#16, #12, #35, and #39) of five residents reviewed for immunizations. The census was 39. Findings include: 1. Review of the medical record for Resident #12 revealed admission date 01/26/22. Diagnoses included, but not limited to, Diabetes Mellitus Type 2 (DM 2), chronic ischemic heart disease, and essential hypertension. Resident #12 was [AGE] years old or older. Further review of Resident #12's medical record revealed there was no evidence the Pneumococcal immunization was offered or administered. 2. Review of the medical record for Resident #16 revealed admission date 03/24/22. Diagnoses included, but not limited to, chronic systolic heart failure and DM 2. Resident #16 was adult 19 through 64 with certain medical conditions. Further review of Resident #16's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-01-12 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
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 and resident interviews, and review of facility policy, the facility failed to complete baseline care plans for residents. This affected three (#4, #193, and #243) of 14 residents in the sample. The census was 39. Findings include: 1. Review of Resident #243's medical record revealed an admission date of 01/05/23. Diagnoses listed included fracture of the left femur, cerebral ataxia, chronic obstructive pulmonary disease, epilepsy, and osteoarthritis. A comprehensive Minimum Data Set (MDS) assessment had not yet been completed. Further of Resident #243's revealed no documentation of a baseline care plan being completed. The Director of Nursing (DON) confirmed during an interview on 01/11/23 at 1:55 P.M. that a baseline care plan was not completed for Resident #243. During an interview on 01/11/23 at 2:00 P.M. Resident #243 stated he did not remember receiving any baseline care plan upon admission to the facility. 2. Review of the medical record for Resident #4 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.
- Potential for harm · Dcited before2023-01-12 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, staff and resident interviews and policy review, the facility failed to initiate a comprehensive care plan for smoking. This affected two (#34 and #9) of two residents reviewed for smoking. Facility census was 39. Findings include: 1. Review of medical record for Resident #34 revealed admission date of 09/06/22 with diagnoses including but not limited to dementia, cannabis abuse, major depressive disorder, post-traumatic stress disorder, and anxiety. Review of Quarterly Minimum Data Set (MDS) for Resident #34 dated 11/11/22 revealed Brief Interview of Mental Status (BIMS) score of 13 which indicated cognitively intact. Resident required supervision with set up help for activities of daily living (ADL's). Review of smoking assessment for Resident #34 dated 09/26/22 revealed the resident had cognitive loss, visual deficit, and no dexterity problem. Smoked two to five cigarettes daily in the morning, afternoon, and evenings. Resident can light own cigarette, required supervision, and facility to store lighter and cigarettes. Plan of care is used to assure…
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 · D2023-01-12 · 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 medical record review, staff interview, and review of facility policy, the facility failed to ensure residents were free from unnecessary psychotropic medications when the facility failed to ensure as needed (PRN) antipsychotic medications was not ordered for longer than 14 days. This affected one (#14) of six residents reviewed for unnecessary medications. The census was 39. Findings include: Review of Resident #14's medical record revealed an admission dated of 08/24/21. Diagnoses listed included dementia without psychotic disturbance, atrial fibrillation, tachycardia, and dorsalgia. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was moderately cognitively impaired and required supervision to limited assistance with activities of daily living (ADL's). Review of physician orders revealed an order dated 11/07/22 for Haloperidol (antipsychotic medication) tablet 0.5 milligrams (mg), give one tablet by mouth every four hours PRN for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-01-12 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, review of facility policy, and review of manufacturer guidelines, the facility failed to ensure staff primed insulin pen devices (insulin pens) before insulin administration resulting in a significant medication error. This affected one (#18) of five residents observed for medication administration. The census was 39. Findings include: Review of Resident #18 medical record revealed an admission date of 03/14/22. Diagnoses listed included chronic kidney disease, osteoarthritis, morbid obesity, and type two diabetes mellitus. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 was cognitively intact with a brief interview for mental status (BIMS) score of 14 and required extensive assistance with activities of daily living (ADL's). Review of physician orders revealed an order dated 03/14/22 for Novolog Flexpen (insulin pen) 100 units per milliliter (units/ml). Inject 16 units subcutaneously (SQ) two times a day for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-01-12 · 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, staff interview, and review of facility policy, the facility failed to ensure staff appropriately disinfected a glucometer device after use. This affected one (#13) of one residents observed for blood sugar checks. The census was 39. Findings include: Review of Resident #13's medical record revealed an admission date of 05/17/21. Diagnoses listed included convulsions, major depressive disorder, chronic kidney disease, overactive bladder, and type two diabetes mellitus. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13 and required extensive assistance with activities of daily living (ADL's). Review of physician orders revealed an order dated 09/27/22 to obtain and record Accu-check blood sugar (finger stick blood glucose) before meals and at bedtime without insulin coverage. On 01/10/23 at 6:37 A.M. Licensed Practical Nurse (LPN) #107 was observed…
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 · F2019-08-28 · tag F0868 — widespreadHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — the official record, unedited, may be distressing
Based on review of the Quality Assessment and Assurance (QAA) minutes, and staff interview, the facility failed to ensure QAA meetings were conducted on a quarterly basis. This had the potential to affect all 58 residents of the facility. Findings include: Review of the quarterly QAA committee meeting minutes revealed a meeting was conducted on 04/06/18. The next meeting was not conducted until 08/09/19. On 08/28/19 at 9:38 A.M. interview with Administrator verified there had not been a QAA committee meeting for over a year per his QAA committee meeting records.
- Potential for harm · Fcited before2019-08-28 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — the official record, unedited, may be distressing
Based on policy review and staff interview, the facility failed to ensure adequate monitoring was completed regarding Legionella. This had the potential to affect all 58 residents of the facility. Findings include: Review of the facility policy and procedure titled, Legionella Policy, dated 07/01/18 revealed the following inspection/services will be performed and documented according to schedule: 1. Weekly: Flushing of little used outlets 2. Monthly: Hot and cold water temperature monitoring 3. Quarterly: Showerhead descaling and disinfection 4. Six monthly: Potable (drinking) water TVC inspection 5. Yearly: Legionella Risk Assessment Review of the Legionella documentation revealed water temperatures were monitored in 08/2019. Interview with Staff #205 on 08/28/19 at 10:10 A.M. confirmed the facility was not completing all the monitoring for Legionella per the facility policy.
- Potential for harm · D2019-08-28 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review and staff interview, the facility failed to ensure residents received a Skilled Nursing Facility Advanced Beneficiary Notice of NON-coverage (SNF/ABN) when cut from Medicare Part A services as required. This affected three residents (#11, #29 and #38) of three reviewed for Notice of Medicare Non-coverage (NOMNC). The facility census was 58. Findings include: 1. Review of the medical record for Resident #11 revealed an admission date of 06/04/17 with diagnoses including cognitive communication deficit, Alzheimer's Disease, and major depressive disorder. Review of notification of discharge from therapy form dated 05/29/19 documented Resident #11 would be discharged for Medicare Part A services on 05/31/19 due to the resident meeting their maximum potential. Review of NOMNC dated 05/31/19 documented a copy was mailed to the Resident #11 representative with no return signature. The review also revealed the resident was not given a SNF/ABN when the resident remained in the facility after being discharged from Medicare Part A services. 2. Review of 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.
“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
$28,743 in federal fines across 1 penalty. 1 Medicare payment denial on record.
- $28,743 — penalty dated 2025-07-21
- Medicare payment denial — starting 2023-12-28 for 15 days
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.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| Ownership Data Not Available |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
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 $579K 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 365566. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-18, 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.