Evergreen Healthcare Center
924 Charlie's Way, Montpelier, OH 43543 · For profit - Corporation · 69 certified beds · (419) 485-8307 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 Jan 2023
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- about 21% of its spending goes to commonly-owned related companies
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) | 3 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 | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 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 | 4.3% | 5.3% | 15.4% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 0.0% | 6.2% | 5.4% | check this* — see note marked star below the table |
| 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 | 10.3% | 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 | 3.2% | 3.2% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 3.7% | 6.1% | 16.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 36.8% | 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 | 8.2% | 3.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 23.7% | 21.4% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 14.0% | 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 | 82.4% | 75.6% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 32.4% | 24.9% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 6.8% | 12.9% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.79 | 1.73 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 2.04 | 1.80 | 1.80 | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ 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.
42.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 32 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 59.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 27 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 0.35 therapist hours per resident per day in 2026Q1 — more than 60% 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 | 42.5%CMS range 30.9–55.4 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.5%CMS range 8.8–19.4 | 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 | 59.3% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 37.0% | 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 | 48.1% | 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 | 3.1% | 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 | 7.9%CMS range 4.2–15.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.18 | 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 69 beds and averages 42.6 residents a day — about 62% occupied, or roughly 26 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.27 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.60 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.67 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 2.94 hrs/resident/day on weekends vs 3.40 on weekdays — 13% thinner on weekends. RN hours go from 0.68 to 0.42 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 46% 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.
27 citations, most serious first. The 12 most serious are shown; the remaining 15 are one tap away and print in full.
- Immediate jeopardy · J2023-01-18 · 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 medical record review, review of a Self-Reported Incident (SRI), staff interviews, review of the local police report, review of the facility investigation, review of email and policy review, the facility failed to ensure one resident (Resident #28) was free from physical abuse by facility staff. This resulted in Immediate Jeopardy and serious negative psychosocial harm, based on a reasonable person's response of fear and anxiety, for Resident #28, who has severe cognitive impairment, when Licensed Practical Nurse (LPN) #431 physically walked Resident #28 back a couple steps to a wall, held her against the wall with her right forearm, and placed her left hand on the resident's throat in response to behaviors Resident #28 was exhibiting, causing Resident #28 to start screaming and crying. This affected one (#28) of four residents (#10, #20, #28, and #30) reviewed for abuse. There was a total of 17 residents (#28, #38, #20, #293, #143, #39, #8, #30, #10, #14, #1, #26, #27, #15, #25, #19, and #36) screened for abuse during the annual survey. The facility census was 44. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2023-01-18 · 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 staff interview, review of the medical records, review of hospital records, and review of the facility policy, the facility failed to implement fall interventions for one (#26). This resulted in Actual Harm when Resident #26's bed was not placed in the low position, the resident fell out of bed and suffered a dislocated left little finger. This affected one (Resident #26) of four residents reviewed for falls. Additionally, the facility failed to ensure post-fall assessments were completed and falls were tracked on the facility's incident log. This affected three (#26, #244, and #245) of four residents reviewed for falls. The facility census was 44. Findings include: 1. Review of the medical record for Resident #26 revealed an admission date of 10/04/22. Diagnoses included Parkinson's disease, history of falling, and oropharyngeal dysphagia. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 12/08/22, revealed Resident #26 had impaired cognition and required extensive assistance of two…
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 · E2026-04-09 · tag F0805 — failed to prepare food in a form residents can eat — patternEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, review of recipe, and review of diet and nutrition manual the facility failed to serve pureed foods at a smooth consistency for safe swallowing. This had the potential to affect five (#3, #16, #20, #22, and #34) residents who the facility identified to require a pureed diet. The facility census was 44. Observation on 04/08/26 at 11:48 A.M. of the first pan of preprepared pureed ham revealed the pureed ham appeared chopped and was separated, not a smooth consistency. Observation of a test tray of the pureed ham revealed the pureed ham was not a smooth consistency.Interview on 04/08/26 at 11:50 A.M. with Dietary Manager #302 verified the first pan of pureed ham was not smooth. Observation on 04/08/26 at 11:55 A.M. of the second pan of preprepared pureed ham revealed the pureed ham appeared to be a smoother texture however there were clumps of what appeared to be ham rind. Interview on 04/08/26 at 11:56 A.M. with Dietary Manager #302 reported the two pans of pureed ham were prepared at the same time but heated separately. Dietary Manager #302…
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 · D2026-04-09 · 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, observation, resident interview, staff interview, review of self-reported incidents, and review of facility policy the facility failed to report incidents of potential misappropriation. This affected one (#27) of one residents reviewed for misappropriation. The facility census was 44. Review of the medical record revealed Resident #27 was admitted on [DATE]. Diagnoses included Type Two Diabetes Mellitus without complications, essential hypertension, hyperlipidemia, chronic kidney disease, anxiety disorder, and lymphedema. Review of the Minimum Data Set (MDS) assessment, dated on 02/04/26, revealed the resident was cognitively intact.Interview on 04/07/26 at 2:16 P.M. with Resident #27 revealed his smart phone was stolen a few months ago. Resident #27 stated he believed it was stolen, not lost as he always left it on his bedside table. Resident #27 stated it was an iPhone 17. Resident #27 stated the police were not called to take report and he was not asked if he desired to make 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 · Dcited before2026-04-09 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
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, resident interview, staff interview, and review of facility policy the facility failed to thoroughly investigate an allegation of misappropriation. This affected one (#27) of one resident reviewed for misappropriation. The facility census was 44. Review of the medical record revealed Resident #27 was admitted on [DATE]. Diagnoses included Type Two Diabetes Mellitus without complications, essential hypertension, hyperlipidemia, chronic kidney disease, anxiety disorder, and lymphedema. Review of the Minimum Data Set (MDS) assessment, dated 02/04/26, revealed the resident was cognitively intact.Interview on 04/07/26 at 2:16 P.M. with Resident #27 revealed his smart phone was stolen a few months ago. Resident #27 stated he believed it was stolen, not lost as he always left it on his bedside table. Resident #27 stated it was an iPhone 17. Resident #27 stated the police were not called to take report and he was not asked if he desired to make a report.Observation 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 · D2026-04-09 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and review of the facility policy, the facility failed to ensure dependent residents received timely facial grooming. This affected one (#3) of three residents reviewed for the provision of activities of daily living in a facility census of 44. Findings include:Resident #3 admitted to the facility on [DATE] with the diagnosis including, dementia, anxiety disorder, pseudobulbar affect, major depressive disorder, hypertension, parkinson's disease, neurocognitive disorder, and schizoaffective disorder. According to the most current minimum data set assessment dated [DATE] Resident #3 was assessed with intact cognition, ability to make needs known, no resistive behavior, range of motion impairment to bilateral upper and lower extremities, required substantial to maximal assistance with activities of daily living, utilized a wheelchair for mobility. On 03/24/26 a nursing plan of care was revised to address Resident #3 activity of daily living (ADL)…
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 · D2026-04-09 · 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, medical record review, staff interview, and review of facility policy, the facility failed to ensure pressure relief interventions were provided to promote wound healing and prevent further deterioration. This affected one (#31) of two residents reviewed with pressure ulcers in a facility. The census of 44. Findings include:Resident #31 admitted to the facility on [DATE] with the diagnosis including, congestive heart failure, chronic obstructive pulmonary disease, Type II Diabetes Mellitus, morbid obesity, chronic respiratory failure, anxiety disorder, hypertension, dementia, chronic peripheral venous insufficiency, osteoarthritis, transient ischemic attack, and dependence on supplemental oxygen. According to the most current minimum data set assessment dated [DATE] Resident #31 was assessed with severe cognitive impairment, no resistive behaviors, range of motion impairment to upper and lower bilateral extremities, utilized a wheelchair propelled by staff, was dependent on staff for all…
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 · D2026-04-09 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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 review of the facility policy, the facility failed to ensure timely incontinence care was provided to a dependent resident. This affected one, (#31) of two residents reviewed for incontinence care services in a facility census of 44. Findings include:Resident #31 admitted to the facility on [DATE] with the diagnosis including, congestive heart failure, chronic obstructive pulmonary disease, Type II Diabetes Mellitus, morbid obesity, chronic respiratory failure, anxiety disorder, hypertension, dementia, chronic peripheral venous insufficiency, osteoarthritis, transient ischemic attack, and dependence on supplemental oxygen. According to the most current minimum data set assessment dated [DATE] Resident #31 was assesed with severe cognitive impairment, no resistive behaviors, range of motion impairment to upper and lower bilateral extremities, utilized a wheelchair propelled by staff, was dependent on staff for 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 · Dcited before2026-04-09 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview and facility policy the facility failed to ensure adequate fluid was provided to dependent resident. This affected one of one residents (#31) reviewed for hydration in a facility census of 44. Findings include:Resident #31 admitted to the facility on [DATE] with the diagnosis including, congestive heart failure, chronic obstructive pulmonary disease, type 2 diabetes mellitus, morbid obesity, chronic respiratory failure, anxiety disorder, hypertension, dementia, chronic peripheral venous insufficiency, osteoarthritis, transient ischemic attack, and dependence on supplemental oxygen. According to the most current minimum data set assessment dated [DATE] assessed Resident #31 with severe cognitive impairment, no resistive behaviors, range of motion impairment to upper and lower bilateral extremities, utilized a wheelchair propelled by staff, dependent on staff for all activities of daily living including transfer and repositioning, always incontinent 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 · D2026-04-09 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, resident interview, staff interview, and review of facility policy the facility failed to ensure timely follow-up for dental concerns. This affected one (#27) of one resident reviewed for dental services. The facility census was 44. Review of the medical record revealed Resident #27 was admitted on [DATE]. Diagnoses included Type II Diabetes Mellitus without complications, essential hypertension, hyperlipidemia, chronic kidney disease, anxiety disorder, and lymphedema. Review of the Minimum Data Set (MDS) assessment, dated on 02/04/26, revealed the resident was cognitively intact and required set-up/clean-up assistance for oral hygiene. Resident #27 had obvious or likely cavity or broken natural teeth. The MDS assessment, dated 02/03/25, also identified obvious or likely cavity or broken natural teeth. Review of most recent care plan, verified Resident #27 had oral/dental problems. Interventions include to complete oral assessment upon admission and as needed, observe…
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 before2026-04-09 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and review of the facility policy, the facility failed to ensure Enhanced Barrier Precautions were followed as ordered by the physician. This affected one of two residents (#2) reviewed for implementation of Enhanced Barrier Precautions. The facility identified 14 current residents(#2, #7, #13, #20, #22, #24, #26, #29, #31, #32, #35, #43, #48, #50) placed in Enhanced Barrier Precautions.Findings include:1. Resident #2 admitted to the facility on [DATE] with the diagnosis including, neoplasm of bone, soft tissue, skin, and endocrine glands, malignant neoplasm of brain, Type II Diabetes Mellitus, neuromuscular dysfunction of bladder, paraplegia, hypertension, coronary artery disease, anxiety disorder, polyneuropathy, cauda equina syndrome and abdominal aortic aneurysm. According to the most current minimum data set assessment dated [DATE] Resident #2 was assessed with intact cognition, range of motion impairment to bilateral lower extremities, utilized…
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 · D2023-01-18 · 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
Based on medical record review, staff interview and facility policy , the facility failed to follow physician orders to notify the physician when blood glucose readings were outside of specific parameters for two residents (#6, #246) and failed to notify the physician of urinalysis results for one (#243) resident. The facility census was 44. Findings include: 1. Review of the medical record of Resident #6 revealed an admission date of 11/12/20. Diagnoses included type II diabetes mellitus with diabetic neuropathy and diabetic retinopathy without macular degeneration. Review of the physician orders dated 11/22/22 revealed an order for Novolog insulin as per sliding scale of blood glucose and if if below 80 or above 400 call the doctor. Review of the Medication Administration Record (MAR) for November and December 2022 revealed the blood glucose results were documented as being in the range the physician was to be notified (below 80 and above 400) on 11/23/22 at 11:00 A.M., on 11/24/22 at 4:00 P.M., on 11/28/22 at 11:00 A.M., on 11/29/22 at 11:00 A.M., on 11/30/22 at 11:00 A.M. 4:00…
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 15 citations
- Potential for harm · Dcited before2023-01-18 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
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 the facility Self-Reported Incidents (SRIs), and review of facility policy, the facility failed to ensure allegation of one resident shoving another resident was investigated and reported to the State Survey Agency. This affected one (#28) of four residents reviewed for abuse. The facility census was 44. Findings include: Review of Resident #28's medical record revealed an admission date of 11/12/22. Diagnoses included Alzheimer's disease, dementia with behavioral disturbance, type II diabetes, anxiety disorder, depression, and insomnia. Review of Resident #28's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of two indicating Resident #28 was severely cognitively impaired. Resident #28 had delusions and displayed physical behavioral and verbal symptoms directed toward others, behavioral symptoms not directed toward others, and wandering behaviors one to three days during the review period. It 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 · D2023-01-18 · 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
Based on staff interview, record review, and review of the facility policy, the facility failed to complete neurological checks after unwitnessed falls and after a witnessed head injury. This affected three (#26, #244 and #245) of four residents reviewed for falls. The facility census was 44. Findings include: 1. Review of the medical record for Resident #26 revealed an admission date of 10/04/22 with medical diagnoses of Parkinson's disease, history of falling, and oropharyngeal dysphagia. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 12/08/22, revealed Resident #26 had impaired cognition and had used extensive assistance of two people for all activities of daily living. He had a fall with minor injury since the previous assessment. Review of the medical record for Resident #26 revealed he had an unwitnessed fall on 10/09/22. Neurological checks were not completed after this fall. Continued review revealed a witnessed fall on 10/20/22 wherein Resident #26 Did a head dive out of his chair, did a summersault, and ended up on his coccyx. Review of the Post-Fall…
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 before2023-01-18 · 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 observation, staff interview, review of meal tickets, and review of the medical record, the facility failed to implement weight loss supplements per physician order after a significant weight loss. This affected one (#26) of two residents reviewed for weight loss. The facility census was 44. Findings include: Review of the medical record for Resident #26 revealed an admission date of 10/04/22 with medical diagnoses of Parkinson's disease, history of falling, and oropharyngeal dysphagia. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 12/08/22, revealed Resident #26 had impaired cognition and required extensive assistance of one person for eating. He had a significant weight loss while not on a prescribed weight-loss regimen and he was on a therapeutically altered diet. Review of the weight history for Resident #26 revealed a weight dated 11/06/22 of 201.0 pounds and a weight dated 12/21/22 of 178.6 pounds. This reflected a significant weight loss of 11.2 percent (%) in less than two months. Review of the nutrition progress note dated 12/19/22 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 · D2023-01-18 · 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, staff interview, and review of the facility policy, the facility failed to ensure the physician reviewed and responded to pharmacist recommendations. This affected one (#10) of five residents reviewed for unnecessary medications. The facility census was 44. Findings include: Review of Resident #10's medical record revealed an admission date of 10/21/21. Diagnoses included dementia, muscle wasting and atrophy, anxiety disorder, depression, and osteoarthritis. Review of Resident #10's Minimum Data Set (MDS) assessment, dated 10/01/22, revealed a Brief Interview for Mental Status (BIMS) score of nine indicating Resident #10 was moderately cognitively impaired. Resident #10 displayed no behaviors during the review period. Review of Resident #10's care plan revised 11/23/22 revealed supports and interventions for a mood problem related to depression. Review of Resident #10's physician orders revealed orders dated 11/06/21 for sertraline hydrochloride (HCL) 25 milligram (mg) in the morning with sertraline HCL 50 mg for depression. Review of Resident #10'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 · D2023-01-18 · 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
Based on medical record review, staff interview, review of manufacturer instructions, review of meal times, and review of the facility policy, the facility failed to administer insulin in accordance with the manufacturer instructions for one (Resident #246) of three residents reviewed for insulin use. The facility census was 44. Findings include: Review of the medical record for Resident #246 revealed an admission date of 09/12/22 and a discharge date of 10/05/22. Diagnoses included displaced intertrochanteric fracture of right femur subsequent encounter, type II diabetes, and morbid obesity. Review of Resident #246's Minimum Data Set (MDS) assessment, dated 09/19/22, revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #246 was cognitively intact. Review of Resident #246's physician orders revealed an order dated 09/12/22 for Insulin Regular Human Injection Solution 100 units per milliliters (ml) inject per sliding scale. An order dated 09/22/22 for Insulin Regular Human Injection Solution 100 units per ml inject 10 units subcutaneously before meals…
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 · D2023-01-18 · tag F0835 — failed to run the facility competently — isolatedAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY AMENDED 02/13/23 Based on review of the facility Self-Reported Incidents (SRI), email communication, and staff interview, the facility failed to substantiate and accurately report the results of an investigation of staff to resident abuse to the State Survey Agency. This affected one (#230588) SRI out of six SRIs reviewed. The facility census was 44. Findings include: Review of the SRI #230588, dated 12/29/22, revealed at approximately 9:30 A.M. it was reported that Licensed Practical Nurse (LPN) #431 had moved Resident #28 against the wall with her forearm. The incident occurred on North Hall and was partially witnessed by some of the nursing staff. The incident occurred as Resident #28 attempted to take LPN #431's narcotic book. LPN #431 stated she put her hand on the book to attempt resident from taking it. This upset Resident #28 and Resident #28 ripped LPN #431's mask off and placed her hand on LPN #431's neck. LPN #431 stated she then used her forearm to move Resident #28 towards the wall to keep 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 · Dcited before2023-01-18 · 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
AMENDED 02/14/23 Based on observation, staff interview and review of the facility policy, the facility failed to ensure infection control practices were adhered to during a dressing change. This affected one (#8) of one resident observed during a dressing change. The facility census was 44. Findings include: Review of the medical record of Resident #8 revealed an admission date of 08/26/22. Diagnoses included malignant neoplasm of larynx, chronic obstructive pulmonary disease, peripheral vascular disease, depression, and anxiety disorder. The resident had a stage II pressure ulcer on the coccyx. Observation on 12/20/22 at 12:25 P.M. revealed Licensed Practical Nurse (LPN) #431 applied gloves and assisted Resident #8 to pull his pants and brief down, exposing his buttocks. LPN #431 removed a small (2 inch by 2 inch) boarded dressing from Resident #8's coccyx. The dressing had a scant amount of reddish drainage noted. The wound was observed to have no depth and appeared to measure approximately 0.5 centimeters (cm) in length and 0.2 cm in width. LPN #431 did not remove her gloves 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 · D2023-01-18 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, review of the infection surveillance log, and review of facility policy, the facility failed to ensure residents receiving an ongoing prophylactic antibiotic had a reason for continued use. This affected one (Resident #294) of six residents reviewed for unnecessary medications. The facility census was 44. Findings include: Review of Resident #294's medical record revealed an admission date of 12/08/22 and a discharge date of 12/26/22. Diagnoses included right arm fracture subsequent encounter with delayed healing, osteoarthritis, anxiety disorder, and depression. Review of Resident #294's Minimum Data Set (MDS) assessment, dated 12/15/22, revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #294 was cognitively intact. Resident #294 had no infections at the time of the review. Review of Resident #294's Care Plan revised 12/20/22 revealed supports and interventions for antibiotic therapy for an infection. The infection 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.
- Potential for harm · D2021-12-21 · 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
Based on record review, observations, staff interview, and review of the facility's policy, the facility failed to ensure residents with indwelling catheters had their catheters managed in a dignified manner. This affected one (Resident #30) of the two residents the facility identified as having indwelling catheters. The facility census was 48. Findings include: Review of Resident #30's medical record revealed an admission date of 04/21/20. Diagnoses included chronic kidney disease, muscle wasting, personal history of COVID-19, Alzheimer's disease, and need for assistance with personal care. Review of the Minimum Data Set (MDS) assessment, dated 11/08/21, revealed Resident #30 was severely cognitively impaired. Resident #30 had an indwelling catheter at the time of the review. Resident #30 required extensive assistance with dressing, toilet use, and personal hygiene. Resident #30 displayed rejection of care behaviors one to three days during the review period. Review of Resident #30's care plan, revised 07/06/21, revealed supports and interventions for catheter care including…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-12-21 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal 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 medical record review, review of the facility's policy, and staff interview, the facility failed to ensure residents and responsible parties were provided a notice of transfer upon transfer from the facility. This affected two (#13 and #51) of two residents reviewed for hospitalizations. The facility identified three residents transferred to the hospital in the past 90 days. The facility census was 48. Findings include: 1. Review of the medical record for Resident #51 revealed the resident was admitted to the facility on [DATE]. Diagnoses include morbid obesity, heart failure hypertensive heart disease, chronic kidney disease stage III, and coronary artery disease. Review of the progress note, dated 09/30/21 at 12:23 P.M., revealed Resident #51 was short of breath and gasping for air, with low oxygen levels. The emergency squad was called and the resident was taken by squad to local hospital. Review of the medical record revealed there was no notice of discharge provided to the resident or responsible…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-12-21 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, review of the facility's policy, and staff interview, the facility failed to ensure residents were provided with bed hold notices upon transfer from the facility. This affected one (#13) of two residents reviewed for hospitalizations. The facility identified three residents discharged to the hospital in the last 90 days. The facility census was 48. Findings include: Review of the medical record for Resident #13 revealed an admission date of 10/06/21. Diagnoses included morbid obesity with alveolar hypoventilation, type II diabetes mellitus with diabetic chronic kidney disease, and heart failure. Review of the admission Minimum Data Set (MDS) assessment, dated 10/13/21, revealed Resident #13 had moderate cognitive impairment. Review of the medical record for Resident #13 revealed Resident #13 was transferred from the facility on 10/29/21 and 11/27/21. Review of the medical record revealed there was no documentation of the resident and resident representative of receiving a bed hold notice from the facility on 10/29/21 and 11/27/21, when Resident #13…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-12-21 · 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
Based on medical record review, resident interview, staff interview, and policy review, the facility failed to provide a copy of the baseline care plan to a resident and their representative. This affected one (Resident #251) of thirteen residents reviewed for care plans. The facility census was 48. Findings include: Review of the medical record for Resident #251 revealed an admission date of 12/17/21. Diagnoses included chronic kidney disease, bipolar disorder, congestive heart failure, essential hypertension, schizoaffective disorder and gastro-esophageal reflux disease. Review of the Minimum Data Set (MDS) assessment revealed it had not yet been completed. Review of the medical record revealed a baseline care plan was completed on 12/17/21 for Resident #251. The baseline care plan was not signed by Resident #251 or their representative as indicated on the care plan. Interview on 12/19/21 at 2:34 P.M. with Resident #251 revealed he never received a copy of his baseline care plan. Interview on 12/21/21 at 11:10 A.M. with the Director of Nursing verified Resident #251 or their…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-12-21 · 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, staff interview, and policy review, the facility failed to provide care and services to monitor a vascular access for a resident that received dialysis. This affected one (Resident #251) of one resident reviewed for dialysis. The facility identified one resident receiving dialysis in the facility. Findings include: Review of the medical record for Resident #251 revealed an admission date of 12/17/21. Diagnoses included chronic kidney disease. Review of the care plan revealed Resident #251 was currently on dialysis therapy for chronic kidney disease stage four. Interventions included dialysis on Tuesday, Thursday and Saturday at 11:00 A.M. Type of dialysis access site was a right permanent catheter. Evaluate the resident following dialysis treatment. Hemodialysis port-if port was located in arm, do not complete blood draws, blood pressures in same arm. Do not remove dressing applied by dialysis center. Evaluate port for bleeding. If bleeding occurs, apply continuous direct pressure to site for at least five minutes, if unable to stop the bleeding call…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-12-21 · 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 medical record review, observation, staff interview, and policy review, the facility failed to administer medications as ordered by the physician with a medication error rate of less than five percent (%). There were three medications errors out of 26 opportunities resulting in a 11.5% medication error rate. This affected two (Resident #4 and #14) of four residents observed for medication administration. The facility census 48. Findings include: 1. Review of the medical record for Resident #4 revealed an admission date of 07/09/20. Diagnoses included Parkinson's Disease and dementia without behavioral disturbance. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/03/21, revealed Resident #4 was cognitively intact. Review of Resident #4's physician orders, dated 07/10/20, revealed an order for calcium carbonate-vitamin D (supplement) 500 milligrams (mg)/200 units one tablet twice a day. Observation on 12/20/21 at 8:09 A.M. of Licensed Practical Nurse (LPN) #206 administer medications to Resident #4 revealed LPN #206 administered calcium with vitamin D 600…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-12-21 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation, staff interview, and policy review, the facility failed to administer eye drops using appropriate infection control practices. This affected one resident (#33) of two residents observed for eye drops. In addition, the facility failed to ensure residents with indwelling catheters had their catheters managed in a sanitary manner. This affected one (#30) of two residents the facility identified as having indwelling catheters. The facility census was 48. Findings include: 1. Observation and interview on 12/20/21 at 7:53 A.M. of Licensed Practical Nurse (LPN) #206 revealed LPN #206 administered medications to Resident #33. LPN #206 administered eye drops to Resident #33 without washing her hands or wearing gloves prior to administration. LPN #206 verified she did not wash her hands prior to administering the eye drops and did not wear gloves. LPN #206 stated she was not aware that she had to wear gloves. Review of the facility's policy titled Liberalized Medication Administration, revised 04/28/21, revealed the general nursing standards of practice…
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 COMMUNICARE HEALTH — 110 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 | 3 of 5 | 3.2 | -0.2 vs chain |
| Health inspection | 3 of 5 | 2.7 | +0.3 vs chain |
| Staffing | 3 of 5 | 2.6 | +0.4 vs chain |
| Quality measures | 4 of 5 | 4.5 | -0.5 vs chain |
The other 109 homes this chain runs (chain average 3.2★, per CMS)
Showing 40 of 109; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| SXCY MSTR LSCO, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 01/01/2022 |
| HEALTH CARE LEASE FACILITIES, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 01/01/2022 |
| SXCY HOLDINGS, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 01/01/2022 |
| ROMEO, DOMINIC | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 04/01/2023 |
| STOLTZ, CHARLES | Individual | CORPORATE OFFICER | — | since 03/01/2018 |
| WILHEIM, RONALD | Individual | CORPORATE OFFICER | — | since 03/01/2018 |
| ROBINAIR MGT CO., LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/01/2018 |
| GROVES, DONNA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 04/14/2023 |
| GUTIERREZ, YVETTE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/05/2021 |
| PARK, KEVIN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/01/2024 |
| C.R. STOLTZ FAMILY INVESTMENT COMPANY INC | Organization | ADP OF THE SNF | — | since 03/01/2018 |
| C.R. STOLTZ IRREVOCABLE TRUST | Organization | ADP OF THE SNF | — | since 03/01/2018 |
| I. ROSEDALE IRREVOCABLE TRUST | Organization | ADP OF THE SNF | — | since 03/01/2018 |
| R.S. WILHEIM IRREVOCABLE TRUST | Organization | ADP OF THE SNF | — | since 03/01/2018 |
| RONALD S WILHEIM 2012 SPOUSAL TRUST | Organization | ADP OF THE SNF | — | since 03/01/2018 |
| ROSEDALE FAMILY INVESTMENT COMPANY, INC | Organization | ADP OF THE SNF | — | since 03/01/2018 |
| RRW, LLC | Organization | ADP OF THE SNF | — | since 03/01/2018 |
| S.L. ROSEDALE IRREVOCABLE TRUST | Organization | ADP OF THE SNF | — | since 03/01/2018 |
| SKILLED HC HOLDINGS, LLC | Organization | ADP OF THE SNF | — | since 03/01/2018 |
| WILHEIM FAMILY INVESTMENT COMPANY, INC. | Organization | ADP OF THE SNF | — | since 03/01/2018 |
CMS files one row per role, so the 26 rows in the source record cover these 20 parties — each is shown once here with every role it holds. Nothing is omitted.
14 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 $1.1M paid to related parties — landlords or management companies under common ownership — equal to about 21% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OH
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Ohio Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 365495. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-09, 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.