Pine Ridge Skilled Nursing And Rehab
463 East Pike Street, Morrow, OH 45152 · For profit - Limited Liability company · 50 certified beds · (513) 899-2801 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- lower-than-typical staff turnover (33% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 0.7% | 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 | 95.5% | 30.1% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 0.0% | 3.2% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents whose ability to walk worsened | 2.1% | 6.1% | 16.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 26.0% | 25.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 97.8% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.0% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 28.0% | 21.4% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 14.7% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.9% | 1.2% | 1.4% | 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.
Therapy staffing: this home’s payroll records show 0.08 therapist hours per resident per day in 2026Q1 — more than 4% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 18% 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| 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 | 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 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 50 beds and averages 48.3 residents a day — about 97% occupied, or roughly 2 beds typically open. It runs essentially full — expect a waiting list. 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 3.02 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.48 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.66 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 2.67 hrs/resident/day on weekends vs 3.16 on weekdays — 15% thinner on weekends. RN hours go from 0.53 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 33% is below the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.
- Potential for harm · Fcited before2026-06-30 · 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, interview, record review, and policy review, the facility failed to ensure the kitchen sanitation was maintained and provide meals in a sanitary manner. This had the potential to affect 47 of 47 residents who received food from the kitchen. The facility identified two (Resident #2 and #3) who did not receive food from the kitchen. The facility census was 49.Findings Include:Observation during initial kitchen tour on 06/28/26 at 8:35 A.M. the following was observed:1. In the reach in refrigerator there was an opened undated package of donuts. There was a plate of food unwrapped with no date or label. There were two large pans of gelatin dessert, undated and unlabeled. The reach in refrigerator had no thermometer inside.The deep freezer had no thermometer inside. There were six wrapped sandwiches dated 06/22/25.There was a plate of sliced tomatoes undated.The upright freezer had a heavy build up of approximately a quarter inch of white frost on top, bottom and on the shelves.2.The refrigerator temperature logs, for three different refrigerators and freezers, had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2026-06-30 · tag F0814 — failed to dispose of garbage properly — widespreadDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and policy review, the facility failed to ensure the kitchen garbage was sealed.This had the potential to affect 47 of 47 residents who received food from the kitchen. The facility identified two (Resident #2 and #3) who did not receive food from the kitchen. The facility census was 49.Findings Include:Observation during initial kitchen tour on 06/28/26 at 8:35 A.M. revealed three garbage cans, not actively in use, were not covered.Interview on 06/28/26 at 8:35 A.M. the Administrator verified the three kitchen garbage cans were not actively in use and should have been covered.Observation on 06/29/26 at 12:15 P.M. with [NAME] #358 verified three garbage cans, which were not actively in use, were not covered.Observation on 06/30/26 at 8:45 A.M. [NAME] #318 verified three garbage cans, which were not actively in use, were not covered.Review of facility policy titled Garbage and Rubbish Disposal, undated revealed all garbage containers shall be provided with tight fitting lids and must be kept covered when stored or not in continuous use. This deficiency…
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 · F2026-06-30 · tag F0908 — failed to keep essential equipment working — widespreadKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and policy review, the facility failed to ensure essential kitchen equipment was operating and maintained in good condition. This had the potential to affect 47 of 47 residents who received food from the kitchen. The facility identified two (Resident #2 and #3) who did not receive food from the kitchen. The facility census was 49.Findings Include:1. Observation during the initial kitchen tour on 06/28/26 at 8:35 A.M. and on 06/30/26 at 12:15 P.M., of the large three-door refrigerator, revealed there was one quarter to one half inch of standing water on the bottom of the refrigerator shelf and dripping from the top of the refrigerator. Bags of food were wet from the dripping water. Observation on 06/28/26 at 1:20 P.M. of a resident refrigerator on the 200 unit revealed the freezer section had a heavy one half inch build-up of white ice on the top and side surfaces. The gasket around the freezer was splintered and did not attach well to the freezer compartment. Interview on 06/28/26 at 1:20 P.M., the Assistant Director of Nursing (ADON) #354 verified…
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 before2026-06-30 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview, and policy review, the facility failed to ensure residents were treated with dignity during meals. This affected two (Resident #37 and #49) of 18 residents observed for dining. The facility census was 49.Findings include:1.Review of the medical record revealed Resident #37 was admitted to the facility on [DATE]. Diagnoses included anxiety disorder, contracture of the left hand, chronic pain, and degeneration of nervous system. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #37 had severely impaired cognition and required partial to moderate assistance when eating.2.Review of the medical record revealed Resident #49 was admitted to the facility on [DATE]. Diagnoses included anxiety disorder, dementia, and Parkinson's Disease. Review of the MDS comprehensive assessment dated [DATE] revealed Resident #49 had severely impaired cognition and required partial assistance for eating.Observation on 06/28/26 at 11:30 A.M. in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-19 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, hospital record review, staff interview, and review of the facility, the facility failed to implement resident tube feeding orders upon admission. This affected one (Resident #19) of three residents reviewed for hospitalization. The facility identified one (Resident #19) with orders for tube feeding. The facility census was 46 residents.Findings include: Review of the medical record for Resident #19 revealed an admission date of 05/14/25 with diagnoses including chronic obstructive pulmonary disease (COPD), major depressive disorder, anxiety disorder, and mild protein-calorie malnutrition. Resident #19 transferred to the hospital on [DATE], was readmitted to the facility on [DATE], was transferred again to the hospital on [DATE], and was readmitted to the facility on [DATE] Review of the Minimum Data Set (MDS) assessment for Resident #19 dated 09/06/25 revealed the resident had intact cognition and required staff assistance with activities of daily living (ADLs.) Review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-11-14 · 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, interview and record review, the facility failed to ensure food items, a kitchen dehumidifier, and the kitchen flooring were maintained in a manner to prevent foodborne illness. This affected 47 out of 47 residents that resided in the facility. The facility census was 47. Findings include: Observation of the kitchen on 11/12/24 at 8:31 A.M. revealed there was a black substance and a gray fuzzy substance on the dehumidifier in the kitchen. There was also black substance built up on the kitchen floor and a frozen pack of raw original bratwurst on a Styrofoam tray that was covered with plastic wrap in the freezer that was next to a bag of frozen asparagus. Interview with Dietary Supervisor #72 on 11/12/24 at 8:31 A.M. verified there was a black substance and a gray fuzzy substance on the dehumidifier in the kitchen. Dietary Supervisor #72 also verified there was also a black substance built up on the kitchen floor and a frozen pack of raw original bratwurst on a Styrofoam tray that was covered with plastic wrap in the freezer that was next to a bag of frozen…
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 before2024-11-14 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident was provided with an adequate privacy curtain. This affected one (Resident #20) of one resident reviewed for privacy. The facility census was 47. Findings include: Review of Resident #20's chart revealed Resident #20 admitted to the facility on [DATE] with diagnoses including type two diabetes mellitus without complications, congestive heart failure, hypothyroidism, hypertension, major depressive disorder, anxiety disorder, chronic kidney disease, insomnia, rheumatoid arthritis, cellulitis of right lower limb, acute respiratory failure with hypoxia, and unspecified psychosis not due to a substance or known physiological condition. Review of Resident #20's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Observation of Resident #20's room on 11/12/24 at 9:30 A.M. revealed the privacy curtain between Resident #20 and Resident #20's roommate's bed did not cover the whole…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-14 · 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 interviews, medical record review, and policy review, the facility failed to ensure the provider and family were notified when medications were unavailable for administration as ordered. The affected two (Residents #42 and #20) of eight residents reviewed for notification. The facility census was 47. Findings include: 1. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE]. Diagnoses included acute on chronic diastolic heart failure, stage three chronic kidney disease, and type two diabetes. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 was cognitively intact, had no behaviors, did not wander, and did not reject care. Review of the medical record revealed progress notes dated 11/11/24, 11/04/24, 10/28/24, 10/21/24, 10/14/24, 10/07/24, and 09/30/24 revealed no documentation of family or provider notification that Ozempic medication was not available and was not given. During an interview on 11/12/24 at 9:36 A.M.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-14 · 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 interview, medical record review, and policy review, the facility failed to ensure residents had comprehensive care plans. This affected two (Residents #42 and #20) of eight residents reviewed for care plans. The facility census was 47. Findings include: 1. Review of the medical record revealed Resident #42 was admitted tot he facility on 08/06/24. Diagnoses included acute on chronic diastolic heart failure, stage three chronic kidney disease, and type two diabetes. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 was cognitively intact, had no behaviors, did not wander, and did not reject care. Review of the care plan dated 08/08/24 revealed no care plans for diabetes, congestive heart failure, and chronic kidney failure. During an interview on 11/14/24 at 10:40 A.M. the Director of Nursing (DON) verified Resident #42's care plan was incomplete and did not address the resident's known medical conditions. 2. Review of Resident #20's chart revealed 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 · D2024-11-14 · 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 — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, medical record review, and policy review, the facility failed to ensure medications were available and administered as ordered. This affected two (Residents #20 and #42) of five residents sampled for medications administration. The facility census was 47. Findings include: 1. Review of the medical record revealed Resident #42 was admitted tot he facility on 08/06/24. Diagnoses included acute on chronic diastolic heart failure, stage three chronic kidney disease, and type two diabetes. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 was cognitively intact, had no behaviors, did not wander, and did not reject care. Review of the medical record revealed Resident #42 had physician orders dated 08/12/24 for Ozempic (0.25 or 0.5 milligram (mg)/dose) Subcutaneous Solution Pen-injector 2 mg/3 milliliters (ml) (Semaglutide) Inject 0.5 mg subcutaneously once weekly every Monday for Diabetes. Review of the Medication Administration Record (MAR) dated…
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 18 citations
- Potential for harm · D2024-11-14 · 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, interview, medical record review and policy review, the facility failed to ensure appropriate signage was posted for residents in transmission-based and enhanced barrier precautions. This affected two (Residents #201 and #6) of two residents reviewed for infection control signage. The facility census was 47. Findings include: 1. Review of the medical record revealed Resident #201 was admitted to the facility on [DATE]. Diagnoses included chronic combined congestive heart failure, unspecified chronic obstructive pulmonary disease, unspecified pulmonary disease, and type two diabetes. Review of the medical record revealed on 11/05/24 revealed Resident #201 was assessed for mental status and was cognitively intact. Review of the medical record revealed Resident #201 had physician orders dated 11/06/24 for isolation precautions two times a day for c-diff toxin. Observation on 11/12/24 at 9:47 A.M. revealed Resident #201 was in his room with the door closed. There was a bin located outside 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 · E2022-03-02 · tag F0576 — patternEnsure residents have reasonable access to and privacy in their use of communication methods.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on resident and staff interviews and review of the local post office business hours the facility failed to ensure residents received mail on Saturdays, delivered to the facility by the post office. This directly affected five residents (#03, #09, #20, #30, and #40) of 11 interviewed and had the potential to affect all 39 residents residing in the facility. Findings include: Interview, during the resident council meeting, on 02/23/22 03:46 PM., revealed residents (#03, #09, #20, #30, and #40) stated no mail was delivered on Saturdays due to no business office staff in the building on Saturdays. The residents reported they received their mail from the activities department. Interview on 02/23/22 at 4:51 P.M., revealed the Activities Director (AD) #21 reported mail was delivered every other Saturday due to the Activity Aide (AA) #22's schedule. AA #22 delivers mail on the Saturdays she worked. AD #21 reported she works Monday through Friday and was not scheduled on Saturdays. Interview on 02/23/22 5:56 P.M., revealed the Administrator reported she was hiring a manager to work…
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 · E2022-03-02 · tag F0585 — failed to handle grievances — patternHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of the resident council minutes, observation and resident and staff interviews the facility failed to ensure they had a grievance policy and procedure, posted information on how to file grievances and designate a Grievance Official. This directly affected five residents (#03, #09, #20, #30, and #40) of 11 interviewed and had the potential to affect all 39 residents residing in the facility. Findings include: Review of the resident council meeting minutes dated from 09/23/21 through 01/25/22 revealed no information was provided to residents on how to file a grievance, no information about how confidentially would be maintained if a grievance was filed. Interview on 02/23/22 03:46 P.M., revealed residents (#03, #09, #20, #30, and #40) complained they were unaware of how to file a grievance. The residents attending the council meeting reported they were not sure who to go to when and if they wanted to file a grievance. Interview on 02/23/22 at 4:51 P.M., the Activities Director (AD) #21 stated she facilitated the resident council meetings held once a month. The AD #21…
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 · E2022-03-02 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 medical record review, staff and resident interview, observations and policy review the facility failed to ensure prescribed medications were not left at the bedside for self-administration without assessment or physician's orders. This affected one resident (#22) of 16 reviewed for medication storage. In addition, expired medications were observed on two of two medications carts and one medication room. This had the potential to affect 13 residents (#05, #09, #16, #19, #20, #22, #29, #32, #33, #36, #39, #40 and #42) who had orders for the expired stock medications. The facility census was 39. Findings include: Medical record review for resident #22 revealed an admission on [DATE]. Diagnoses included Covid-19, chronic obstructive pulmonary disease, stroke, carpal tunnel syndrome, hypertension, dry eye syndrome, depression, anxiety, alcohol induced dementia, tremor, osteoarthritis, hyperlipidemia, benign prostatic hyperplasia and insomnia. Review of the Minimum Data Set (MDS) dated [DATE] 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 before2022-03-02 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and staff interview the facility failed to ensure a resident urine collection bag was covered. This affected one resident (#02) of two residents reviewed for dignity. The facility census was 39. Findings include: Medical record review for Resident #02 revealed an admission date of 06/24/22. Diagnoses included diabetes, anemia, heart disease, dementia, Alzheimer's and schizophrenia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #02 had impaired cognition and required extensive assistance for bed mobility and transfers. Resident #02 required the use of an indwelling urinary catheter due to obstruction. Review of the plan of care dated 02/04/22 revealed resident #02 was at risk for bladder infections, and urinary obstruction. Observations of the resident on 02/22/22 at 12:30 P.M. revealed Resident #02 was in bed. The residents' door to the hall was open and from the hall the resident's catheter urine collection bag could be seen.…
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 · D2022-03-02 · 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 medical record review, observation and staff interview the facility failed to ensure Minimum Data Set (MDS) assessments were coded accurately. This affected two residents (#12 and #34) of three reviewed for MDS accuracy. The facility census was 39. Findings included: 1. Medical record review for Resident #34 revealed an admission on [DATE] with a readmission on [DATE]. Diagnoses included pneumonia, chronic respiratory failure, diabetes, repeated falls, anemia, hypertension, anxiety, hypothyroidism, gastro-esophageal reflux disease, major depressive disorder, and cancer of the mouth with gastrostomy tube placement. Review of the comprehensive MDS assessment dated [DATE] for Resident #34 revealed intact cognition. Resident #34 required supervision for bed mobility, transfers, eating and toilet use from one staff member. No dressing to the abdominal gastrostomy tube was coded during the look back period. Review of the plan of care for Resident #34 dated 07/01/19 without revisions revealed the resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-03-02 · 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 record review, observation and staff interview the facility failed to complete a base line plan of care. This affected two residents (#15 and #293) of three sampled for a baseline plan of care. The facility census was 39. Findings include: 1. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE]. Diagnoses included cute kidney failure, diabetes, carotid artery disease, hypertension, and heart block. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #15 had no cognitive deficits, and required extensive assistance with activities of daily living, and was occasionally incontinent of bladder and was always continent of bowel. Review of the record revealed there was no baseline care plan for Resident #15 who was a newly admitted resident. Interview on 02/24/22 at 12:30 P.M., with the Administrator verified baseline care plans were not located in the record and she believed they were not completed upon admission. 2. Review of the medical record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-03-02 · 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, observations, and review of the Resident Assessment Instrument (RAI) manual version 3.0, the facility failed to develop a comprehensive care plan within 14 days after admission to the facility. This affected two residents (#06 and #22) of three reviewed for care plan completion. The facility census was 39. Findings included: 1. Medical record review for Resident #06 revealed an admission date on 11/02/21. Diagnoses included dehydration, dementia with behavioral disturbances, mood disorder, altered mental status and Covid-19. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #06 revealed the resident required supervision for bed mobility, transfers, toilet use and eating. Resident #06 walked independently. Review of the physician order dated February 2022 for Resident #06 revealed an order for a Wanderguard to the residents extremity. Verify placement of the Wanderguard every shift for confusion dated 11/02/21, an order…
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 · D2022-03-02 · 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, resident and staff interview and policy review the facility failed to ensure residents were provided and involved in care conferences to allow resident input in their care. This affected two residents (#01 and #14) out of four residents reviewed. The facility census was 39. Findings include: 1. Medical record review revealed Resident #01 was admitted on [DATE]. Diagnoses included COVID-19, anemia, chronic obstructive pulmonary disease, type 2 diabetes, morbid, primary insomnia, major depressive disorder, gastrointestinal hemorrhage, paroxysmal atrial fibrillation, iron deficiency, chronic diastolic congestive heart failure, chronic kidney disease stage 3, dyspnea and hypertension. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #01 had no cognitive impairment and required supervision for activity of daily living. The record review revealed there was no evidence of a care conference. Interview with Resident #01 on 02/22/22 at 1:19 P.M., revealed she could 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 · D2022-03-02 · 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, staff interview, observation and policy review the facility failed to follow physician ordered as needed pain medication. This affected one resident (#22) of three residents reviewed for pain management. The facility census was 39. Findings include: Medical record review for resident #22 revealed an admission date on 06/02/21. Diagnoses included Covid-19, chronic obstructive pulmonary disease, stroke, carpal tunnel syndrome, hypertension, dry eye syndrome, depression, anxiety, alcohol induced dementia, tremors, osteoarthritis, hyperlipidemia, benign prostatic hyperplasia, and insomnia. Review of the most recent Minimum Data Set (MDS) dated [DATE] revealed Resident #22 had intact cognition. Resident #22 required extensive assistance for bed mobility, transfers, and toilet use. Resident #22 required supervised eating. Resident #22 had functional limitations in range of motion on both the upper and the lower extremities. Resident #22 was assessed for pain and reported no pain during…
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 · D2022-03-02 · 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 medical record review, staff interview, observation, review of the hospital discharge notes and policy review the facility failed to assess a resident for elopement before applying a security system pendent. This affected one resident (#06) of one reviewed for elopement. The facility census was 39. Findings include: Medical record review for Resident #06 revealed an admission date on 11/02/21. Diagnoses included dehydration, dementia with behavioral disturbances, mood disorder, altered mental status and Covid-19. Review of the comprehensive Minimum Data set (MDS) assessment dated [DATE] revealed revealed Resident #06 had impaired cognition. Resident #06 required supervision for bed mobility, transfers, eating and toilet use. Resident #06 was always continent of bowel and bladder. Review of the most recent quarterly MDS assessment dated [DATE] revealed Resident #06 had impaired cognition. Resident #06 required supervision for bed mobility, transfers, eating and toilet use. No wandering behavior was coded…
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 · D2022-03-02 · 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 record review, staff interview, review of hospital documentation and policy review the facility failed to consistently monitor and provide interventions to prevent resident weight loss. This affected one resident (#35) of four residents reviewed for nutrition. The facility census was 39. Findings included: Review of the medical record for Resident #35 revealed an admission date of 12/14/21. Diagnoses included Hypertension, atrial fibrillation, hyperlipidemia, mood disorder, diabetes mellitus, restless leg syndrome, chronic pain, and vitamin D deficiency. Review of the admission nursing assessment for Resident #35 identified the resident was admitted with a weight of 185 pounds (lbs.) on 12/15/21. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #35 dated 01/30/22 revealed the resident had intact cognition. a brief interview for mental status (BIMS) score of 15. No hallucinations, delusions, or rejection of care was noted on the assessment. The resident was independent for eating. The assessment indicated the resident had a weight of 136 pounds, had no…
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 before2022-03-02 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview and policy review the facility failed to evaluate a resident for self-administration of gastrostomy nutritional feedings. Additionally, the facility failed to obtain physician orders for self-administered gastrostomy solutions. This affected one resident (#34) of one reviewed for nutritional need via a feeding tube. The facility census was 39. Findings included: Medical record review for Resident #34 revealed an admission on [DATE] with a readmission on [DATE]. Diagnoses included pneumonia, chronic respiratory failure, diabetes, repeated falls, anemia, hypertension, anxiety, hypothyroidism, gastro-esophageal reflux disease, major depressive disorder, and cancer of the mouth with gastrostomy tube placement. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 had intact cognition. Resident #34 required supervision for bed mobility, transfers, eating and toilet use from one staff member. Resident #34 was coded…
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 · D2022-03-02 · 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, observation and staff interview the facility failed to ensure as needed psychotropic medications were limited to 14 days and not continued unless the prescribing physician evaluated the appropriateness of the medication. This affected one resident (#02) of five residents reviewed for unnecessary medication. The facility census was 39. Findings include: Medical record review for Resident #02 revealed an admission date of 06/24/22. Diagnoses included diabetes, anemia, heart disease, dementia, Alzheimer and schizophrenia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had impaired cognition. Resident #02 required extensive assistance for bed mobility and transfers. Review of the plan of care for Resident #02 dated 02/04/22 revealed the resident was at risk for exhibiting side effects of psychotropic medication related to the use of antipsychotic medication. Routine Xanax (antianxiety medication) 0.5 milligram (mg) three times daily,…
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 before2022-03-02 · 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 record review and resident and staff interview the facility failed to provide routine dental services including inspection of the oral cavity at least annually. This affected one resident (#12) of 16 residents reviewed for dental services. The facility census was 39. Findings include: Review of Resident #12's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic diastolic congestive heart failure, methicillin resistant staphylococcus aureus infection as the cause of diseases classified elsewhere, unspecified asthma, diabetes mellitus, major depressive disorder recurrent, anxiety disorder, and generalized anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had intact cognition. Further review of Resident #12's medical record revealed the last dental visit was dated 03/04/19. Review of a social services note dated 07/30/19 at 2:49 P.M. revealed Resident #12 had complained of an aching tooth.…
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 · E2019-08-01 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, resident interviews, and review of the facility policy, the facility failed to maintain comfortable air temperatures throughout the building. This affected 15 ( #4, #5, #11, #13, #21, #22, #23, #24, #26, #29, #31, #36, #37, #42, and #44) who were observed to show signs of being cold or who complained about the facility temperatures The facility census was 43. Findings include: Observations on 07/29/19 at 10:15 A.M., revealed the temperature on the 200 Hall and 300 Hall was at 70 degrees Fahrenheit (F). Observations during the Resident Council meeting on 07/31/19 at 10:47 A.M., revealed Resident #36 wore a winter sweater with a turtle neck. Residents #23, #5, #42 and #26 wore jackets to the meeting. Interviews during the Resident Council meeting on 07/31/19 at 10:47 A.M., Residents #36, #23, #26, #2, #42, #40, and #5 reported the facility was too cold. Observations on 07/31/19 at 11:50 A.M. of the common area revealed Resident #13 had a blanket covering her neck to her feet, Resident #5 was wearing a jacket, Resident #29 had a button -up sweater…
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 · D2019-08-01 · 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 and staff interview, the facility failed to timely act on a medication regimen review (MRR) for one (#26) of five residents reviewed for unnecessary medications. The census was 43. Findings include: Medical record review for Resident #26 revealed an admission date of 09/28/18. Medical diagnosis included depression. Review of quarterly the Minimum Data Set (MDS) assessment, dated 06/10/19, revealed Resident #26 was cognitively intact. Review of physician order dated 09/28/18 revealed an order for the antideprassant citalopram 40 milligrams (mg) daily. Review of the MRR dated 01/16/19 revealed Resident #26 received citalopram 40 mg daily and the maximum recommended dose was 20 mg. The form asked the physician to please consider decreasing the dose to 20 mg per day. In the physician section it was check marked I agree with this recommendation and written on the form was to decrease citalopram to 30 mg by mouth every day. The form revealed the physician signed in the physician signature box, however there was no date indicating when the physician responded…
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 before2019-08-01 · 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
Based on resident interview, staff interviews and record review, the facility failed to arrange a dental appointment for an oral surgeon after a referral was ordered by the facility dentist. This affected one (#12) of two residents reviewed for dental. The facility census was 43. Findings include: Review of the medical records for Resident #12 revealed an admission date of 09/05/17. Diagnoses included end stage renal disease (ESRD), diabetes mellitus type two, and dependence on renal dialysis. Review of the dental note dated 04/30/19, written by the facility dentist, revealed Resident #12's tooth #3 was broken and tooth #12 was only a root tip. The note documented the dental work needed to be done by an oral surgeon and the facility dentist had left a referral. The note indicated Resident #12 wished to have a new upper partial made. Interview on 07/29/19 at 10:56 A.M. with Resident #12 revealed he had not seen a dentist for four months. He stated he saw the facility dentist a few months ago and he was supposed to have a referral made to have dental work done. He further stated he…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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 HILLSTONE HEALTHCARE — 9 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 | 3.9 | -0.9 vs chain |
| Health inspection | 2 of 5 | 3.3 | -1.3 vs chain |
| Staffing | 2 of 5 | 1.8 | +0.2 vs chain |
| Quality measures | 5 of 5 | 5.0 | ≈ chain avg |
The other 8 homes this chain runs (chain average 3.9★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| BERGSTEN, PAUL | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 05/01/2022 |
| DAPORE, MATTHEW | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 05/01/2022 |
CMS files one row per role, so the 4 rows in the source record cover these 2 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
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.
About 72% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $240K 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 365878. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-11-14, 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 →
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