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Woodside Village Care Center

841 W Marion Rd, Mount Gilead, OH 43338 · For profit - Limited Liability company · 75 certified beds · (419) 947-2015 Medicare & Medicaid certified

Call the home — (419) 947-2015 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Jun 2025
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2025
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • 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.

3/5
CMS overall
3 of 5
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

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
651 West Marion Street First Floor · (740) 383-8080 · Call to confirm hours
Pharmacy
525 W Marion St · (419) 947-1404 · Call to confirm hours
Grocery
Kroger0.6 mi
555 W Marion St · (419) 947-9191 · Call to confirm hours
Park
4119 OH-95 · (419) 946-1961 · Typically dawn to dusk
Place of worship
140 E High St · (419) 946-1913

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 2 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 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.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased14.2%5.3%15.4%typical
Long-stay residents who lose too much weight2.4%6.2%5.4%better
Long-stay residents with a catheter left in their bladder0.9%0.2%0.9%typical
Long-stay residents with a urinary tract infection0.9%0.4%2.0%worse than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms0.5%30.1%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury1.8%3.2%3.3%better
Long-stay residents whose ability to walk worsened11.4%6.1%16.1%worse than state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication25.6%25.5%18.9%worse
Long-stay residents given the seasonal flu vaccine98.2%94.5%95.3%typical
Long-stay residents with pressure ulcers4.3%3.4%4.7%typical
Long-stay residents with worsening bladder/bowel control9.5%21.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table3.9%8.8%17.1%better
Short-stay residents who newly got an antipsychotic medication4.1%1.2%1.4%worse
Short-stay residents given the seasonal flu vaccine48.1%75.6%79.4%worse
Short-stay residents rehospitalized after admission30.4%24.9%22.6%worse
Short-stay residents with an outpatient ER visit13.8%12.9%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.541.731.67typical
Long-stay outpatient ER visits per 1,000 resident days0.541.801.80better

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.

59.5% 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 35 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

59.5%U.S. median 51.5%
Got home and stayed home
9.6%U.S. median 10.7%
Went back to hospital
0.45U.S. median 0.31
Therapy hours / resident / day
0.20hours / resident / day
Physical therapy
0.24hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.45 therapist hours per resident per day in 2026Q1 — more than 75% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 26% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF59.5%CMS range 46.9–71.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.6%CMS range 6.1–14.310.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.6%CMS range 3.8–13.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.241.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.85
RN hours/ resident / day
0.45
LPN hours/ resident / day
1.79
Aide hours/ resident / day
3.10
Total nurse hours/ resident / day
0.51
RN hoursweekends
40.4%
Total nursing turnover
33.3%
RN turnover

How full it usually is: this home is certified for 75 beds and averages 64.1 residents a day — about 85% occupied, or roughly 11 beds typically open. It runs fairly full. 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 3.10 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.85 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.79 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 2.59 hrs/resident/day on weekends vs 3.30 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 0.99 to 0.51 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 40% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

11
deficiencies at the latest standard inspection (2025-01-30)
7
at the previous standard inspection (2023-11-16)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

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

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

29 citations, most serious first. The 10 most serious are shown; the remaining 19 are one tap away and print in full.

  • Potential for harm · D2025-06-02 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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 observation, interview and record review, the facility failed to ensure residents were free from abuse by Certified Nursing Assistant (CNA) #102. This affected one (Resident #12) of seven residents reviewed for abuse. The facility census was 67. Findings include: Review of the medical record for the Resident #12 revealed an admission date of 05/23/25. Diagnoses included dementia, encephalopathy, hypertension, diabetes mellitus, and end stage renal disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/13/25, revealed the resident had impaired cognition. The resident required assistance for mobility, transfers, bathing and feeding. Review of the nursing progress notes dated from 03/01/25 to 06/02/25 revealed Resident #12 had increased agitation and observed behaviors of hitting and kicking facility staff members when they were performing care. Review of the plan of care dated 06/02/25 revealed she was receiving antipsychotic medication to control her behavioral disturbances and sundowning. Review of the facility's investigation file, completed by 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-02 · tag F0609 — failed to report abuse allegations — isolated
    Timely 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

    Based on observation, interview and record review, the facility failed to report the results of an allegation of abuse to the State Survey Agency. This affected one (Resident #12) of seven residents reviewed for abuse. The facility census was 67. Findings include: Review of the medical record for Resident 12 revealed an admission date of 05/23/25. Diagnoses included dementia, encephalopathy, hypertension, diabetes mellitus, and end stage renal disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/13/25, revealed the resident had impaired cognition. The resident required supervision for bed mobility, transfers, ambulation. Review of behavior and mood. Review of the nursing progress notes dated from 03/01/25 to 06/02/25 revealed Resident #12 had increased agitation and observed behaviors of hitting and kicking facility staff members when they were performing care. Review of the facility's investigation file, completed by the Director of Nursing (DON) dated 05/27/25 and timed 11:00 A.M. revealed on 05/27/25, CNA #102 was assisting Resident #12 during breakfast.…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-02 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    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 a staff member was removed from resident care while an allegation of abuse was being investigated. This affected one (Resident #12) of seven residents reviewed for abuse. The facility census was 67. Findings include: Review of the medical record for Resident #12 revealed an admission date of 05/23/25. Diagnoses included dementia, encephalopathy, hypertension, diabetes mellitus, and end stage renal disease. Review of the facility's investigation file, completed by the DON dated 05/27/25 and timed 11:00 a.m. revealed on 05/27/25 CNA #102 was assisting Resident #12 during breakfast. Resident #12 was swinging her arms and attempting to kick CNA #102. CNA #102 held down Resident #12 arms to restrain Resident #12 from punching CNA #102. Resident #12 then leaned her head down toward CAN #102's right arm and attempted to bite CNA #102. CNA #102 took her open left hand and struck Resident #12 in the face, intending to thrust Resident #12's head back so she did not bite CNA #102. Review of the time punch card…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-01-30 · tag F0880 — failed to prevent and control infections — widespread
    Provide 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, and staff interviews, and review of facility policy, the facility failed to ensure proper infection control practices were maintained for residents, team members, and visitors in the facility's water pathogen risk reductions. This had the potential to affect all residents residing at the facility. The facility census was 62. Findings include: Record review on 01/29/25 and 01/30/25 between 7:30 A.M. and 4:15 P.M. revealed the facility was unable to provide the water management team members and logs of the facility's continual assessment, mitigation, and monitoring of the facility's water system. Observation and tour of the facility on 01/29/25 and 01/30/25 between 7:30 A.M. and 4:15 P.M. revealed the facility's representative had not tested or provided the ability to test or assess the water system for controls such as chlorine. Review of the facility policy titled Water Pathogen Risk Reduction, originally dated 01/2016 and updated on 01/01/25, stated the facility will assign a water management team which included facility leadership…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-01-30 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and policy review, the facility failed to ensure the kitchen was kept in a clean and sanitary condition. This deficient practice had the potential to affect all residents in the facility except for Resident #52 who received nothing by mouth. The facility census was 62. Findings include: 1. Observation on 01/27/25 at 08:39 A.M. of the kitchen revealed there is a large hole-like area on the wall behind the steamer. Interview on 01/27/25 at 08:41 A.M. with Dietary Supervisor #41 confirmed the large hole-like area on the wall behind the steamer. Observation on 01/28/25 at 11:16 A.M. revealed there is a large hole like area on the wall behind the steamer. Interview on 01/28/25 at 11:16 A.M. with Dietary [NAME] #59 confirmed the large like hole area on the wall behind the steamer. Interview on 01/28/25 at 11:17 A.M. with Local Health Department Inspector #90 revealed she had cited the hole in the wall on the last three health inspection reports. Review of the County Health Department Food Inspection Report, dated 01/28/25 revealed there is damage to…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-30 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review and staff interview, the facility failed to provide and document all the required information at the time a beneficiary notice was given. This affected three residents (#11, #21, and #320) of three reviewed for beneficiary notices. The facility census was 62. Findings include: 1. Review of the medical record for Resident #11 revealed an admission date of 04/07/22. Diagnoses included myocardial infarction, chronic obstructive pulmonary disease (COPD), hyperlipidemia, type II diabetes, chronic kidney disease, hypertension, chronic respiratory disease, atrial fibrillation, osteoarthritis, gout, major depressive disorder, atherosclerotic heart disease, anxiety disorder, lymphedema, congestive heart failure, and anemia. Review of Resident #11's Minimum Data Set (MDS) assessment, dated 11/26/24, revealed the resident was cognitively intact. Review of Resident #11's intent to discharge from rehabilitation, dated 08/29/24, revealed Resident #11 was receiving physical and occupational therapy and had reached the highest potential and was beginning to plateau.…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-30 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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 record review, interview, observation, and policy review the facility failed to ensure comprehensive care plans were updated. This affected two residents (#11 and #29) of two reviewed for falls. The facility census was 62. Findings include: 1. Review of medical record for Resident #11 revealed an admission date of 04/07/22 with diagnoses including but not limited to type two diabetes, hypertension, atrial fibrillation, major depressive disorder, and anxiety disorder. Review of minimum data set (MDS) dated [DATE] revealed Resident #11 was cognitively intact. Resident #11 was independent for transfers. Review of care plan dated 04/08/22 revealed the following interventions regarding falls: physical educated to hang coat on the hook at the end of the bed (03/28/23), obtain orthostatic blood pressures every shift ordered 01/10/23, and orthostatic blood pressure monitoring for three days (09/09/22). Review of vitals in Matrix revealed no orthostatic blood pressure monitoring. Observation on 01/30/25 at 8:43…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-30 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, staff interview, and facility policy review, the facility failed to have physician orders for a treatment that was being performed and did not clarify treatment orders for existing pressure injuries. This affected one resident (#7) of three residents reviewed for pressure ulcers. The facility census was 62. Findings include: Review of the medical record revealed Resident #7 was admitted to the facility on [DATE]. Diagnoses included sepsis, type II diabetes, chronic obstructive pulmonary disease (COPD), obstructive and reflux uropathy, dysphagia, unspecified protein calorie malnutrition, major depressive disorder, urinary tract infection, tachycardia, contracture of right hand and elbow, elbow, acute cystitis without hematuria, neuromuscular dysfunction of bladder, hypothyroidism, systemic inflammatory response syndrome, hypertension, edema, other malaise, retention of urine, mood disorder, primary optic atrophy, acute embolism and thrombosis, insomnia, osteoporosis, 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-30 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide 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 record review, staff interview, and observation the facility failed to ensure the resident had an understanding of pleasure foods. This affected one (Resident #03) of one reviewed for diet. The facility census was 62. Findings include: Review of medical record for Resident #03 revealed an admission date of 11/03/10 with diagnoses including but not limited to Parkinson's disease, abnormal posture, cognitive communication deficit, altered mental status, pneumonia, adult failure to thrive, history of personality disorder, anxiety, major depressive disorder, schizophrenia, and bipolar disorder. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #03 had moderate cognitive impairment. Resident #03 required setup or clean-up assistance for eating. Review of current physician orders revealed Resident #03 was on puree diet, with a sugar substitute, no added salt, nectar thick liquids, and required the use of a cup with a lid, required a two handled cup for hot liquids and food in bowls.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-30 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and facility policy review, the facility failed to provide proper parameters for as needed pain medication orders and did not document pain levels for all uses of as needed pain medication. This affected one (Resident #39) of one residents reviewed for pain management. The facility census was 62. Findings include: Review of the medical record for Resident #39 revealed the resident was admitted to the facility on [DATE]. Diagnoses included pneumonia, hypotension, hypoxemia, chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure, tremor, cerebral infarction, transient cerebral ischemic attack, dysphagia, hypertension, pure hypercholesterolemia, glaucoma, diplopia, low back pain, and gastrostomy status. Review of Resident #39's Minimum Data Set (MDS) assessment, dated 12/30/24, revealed the resident had a mild cognitive impairment. Review of Resident #39's current physician orders revealed an order for acetaminophen 325 milligrams (mg),…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 19 citations
  • Potential for harm · D2025-01-30 · tag F0805 — failed to prepare food in a form residents can eat — isolated
    Ensure 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to ensure a diet order was processed in a timely manner. This affected one (#03) of one resident reviewed for diet. The facility census was 62. Findings include: Review of medical record for Resident #03 revealed an admission date of 11/03/10 with diagnoses including but not limited to Parkinson's disease, abnormal posture, cognitive communication deficit, altered mental status, pneumonia, adult failure to thrive, history of personality disorder, anxiety, major depressive disorder, schizophrenia, and bipolar disorder. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident #03 had moderate cognitive impairment. Resident #03 required setup or clean-up assistance for eating. Review of current physician orders revealed Resident #03 was on pureed diet, with a sugar substitute, no added salt, nectar thick liquids, and required the use of a cup with a lid, required a two handled cup for hot liquids and food in bowls. Resident #03 may…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-30 · tag F0847 — isolated
    Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
    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, resident interview, family interview, and policy review the facility failed to ensure residents and/or representatives were informed in a manner that was understandable regarding arbitration agreements. This affected four residents (#30, #45, #317, and #318) of four residents reviewed for arbitration agreements. The facility identified 48 residents with signed arbitration agreements. The facility census was 62. Findings include: 1. Review of medical record for Resident #30 revealed an admission date of 07/27/23 with diagnoses including but not limited to dementia, atrial fibrillation, type two diabetes, atherosclerotic heart disease, repeated falls, diverticulitis, gout, restless leg syndrome, and fibromyalgia. Review of Resident #30's Minimum Data Set (MDS) dated [DATE] revealed a brief interview of mental status (BIMS) score of 10 which indicated moderate cognitive impairment. Interview on 01/30/25 at 12:42 P.M. with Resident #30 revealed the resident stated her husband signed her…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-30 · tag F0881 — failed to use antibiotics responsibly — isolated
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, staff interview, and facility policy review, the facility failed to provide adequate justification for the use of antibiotic medication. This affected two (Residents #7 and #21) of five residents reviewed for medication regimens. The facility census was 62. Findings include: 1. Review of the medical record for Resident #7 revealed an admission date of 03/01/08. Diagnoses included sepsis, type II diabetes, chronic obstructive pulmonary disease (COPD), obstructive and reflux uropathy, dysphagia, unspecified protein calorie malnutrition, major depressive disorder, urinary tract infection, tachycardia, contracture of right hand and elbow, elbow, acute cystitis without hematuria, neuromuscular dysfunction of bladder, hypothyroidism, systemic inflammatory response syndrome, hypertension, edema, other malaise, retention of urine, mood disorder, primary optic atrophy, acute embolism and thrombosis, insomnia, osteoporosis, and multiple sclerosis. Review of Resident #7's Minimum Data Set (MDS) assessment, dated 11/07/24, revealed the resident had a mild…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, review of facility investigation, and policy review, the facility failed to ensure adequate supervision of residents when Resident #5 eloped from the facility. This deficient practice affected one (Resident #5) out of three residents reviewed for elopement. The facility census was 64. Findings include: Review of the medical record for Resident #5 revealed an admission date of 01/18/24 with diagnoses including dementia, spondylosis without myelopathy or radiculopathy, depression, and post-traumatic stress disorder. Review of physician orders revealed Resident #5 had an order dated 01/27/24 for a wanderguard in place to his left ankle and placement and function was to be checked each shift. Review of Resident #5's care plan dated 02/07/24 revealed the resident experienced wandering that placed the resident at risk of getting into potentially dangerous places with an intervention that included check left ankle wander guard placement and function per facility protocol. Another care…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-11-16 · tag F0655 — pattern
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, family, resident, and staff interviews, and review of the facility policy, the facility failed to provide a copy of the baseline care plan to the resident and their representative. This affected four (Residents #49, #117, #121, and #219) of 17 residents reviewed for care plans. The facility census was 69. Findings include: 1. Record review for Resident #219 revealed an admission date of 11/11/23. Diagnoses included cutaneous abscess of left lower limb, diabetes mellitus, cerebral infarction, and congestive heart failure. Review of the baseline care plan, initiated on 11/11/23, revealed Resident #219 was a new admission to the facility and was in need of nursing care services. Resident #219 required assistance with activities of daily living. There was no evidence the baseline care plan included Resident #219 and there was no evidence Resident #219 received a copy of the baseline care plan An interview on 11/15/23 at 4:03 P.M. with Unit Manager (UM) #714 revealed she 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-16 · tag F0553 — failed to let residents help plan their care — isolated
    Allow resident to participate in the development and implementation of his or her person-centered plan of care.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, resident interview, and staff interview, the facility failed to ensure residents were invited to attend their care conference, and encouraged to participate in the development, implementation, and revision of the person-centered care plan. This affected one (Resident #51) of 17 residents reviewed for care plans. The facility census was 69. Findings include: Review of the medical record for Resident #51 revealed an admission date of 12/17/21. Diagnoses included type II diabetes mellitus, cerebral infarction, and acute on chronic congestive heart failure. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/13/23, revealed Resident #51 was cognitively intact. Resident #51 was not coded as having any behaviors or rejection of care. Review of Resident #51's care plan revealed the care plan did not mention Resident #51 refused or rejected care. Review of the care conference progress notes revealed Resident #51 had two care conferences in the past 12 months on 11/08/22 and 02/08/23. On 11/08/22, the only recorded participants were Resident #51…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-16 · tag F0585 — failed to handle grievances — isolated
    Honor 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews, record reviews, and review of the facility policy, the facility failed to timely investigate reported missing personal items and follow up with the residents with results of the investigation. This affected one (Resident #14) of one resident reviewed for missing items. The facility census was 69. Findings include: Record review for Resident #14 revealed an admission date of 04/03/21. Diagnoses included hypertensive heart and chronic kidney disease with heart failure and stage one through stage four chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was cognitively intact. Review of the Missing Item Report dated 10/20/23 revealed Resident #14 had reported pajamas that were black with white magnolia flowers that were missing along with a blanket that was grey brown on one side and the other side was white with colored rectangles and a tag that said 'BB'. The Missing Item Report dated 10/27/23 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-16 · tag F0625 — isolated
    Notify 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review, and review of the facility policy, the facility failed to timely provide a resident with the bed hold policy acknowledgement to include the number of bed hold days. This affected one (Resident #64) of one resident reviewed for receipt of bed hold days upon facility transfer of a resident. The facility census was 69. Findings include: Record review for Resident #64 revealed an admission date of 08/27/22. Diagnoses included malignant neoplasm of bladder and acute respiratory failure with hypoxia. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 was cognitively intact. Review of the face sheet for Resident #64 revealed Resident #64 had no information available for contacts. Review of the facility census for Resident #64 revealed on 05/07/23, Resident #64 had a hospital leave and returned to the facility on [DATE]. On 05/14/23, Resident #64 had a hospital leave and returned to the facility on [DATE]. On 08/13/23, Resident #64 had 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-16 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to accurately code the resident's Minimum Data Set (MDS) 3.0 assessments. This affected three (#10, #50, and #51) of 17 residents reviewed during the investigative process. The facility census was 69. Findings include: 1. Review of the medical record for Resident #10 revealed an admission date of 10/19/23. Diagnoses included metabolic encephalopathy, expressive language disorder, and intellectual disabilities. Review of the admission MDS 3.0 assessment, dated 10/23/23, revealed Resident #10 was coded to have bipolar disorder. Review of the medical record revealed no evidence that Resident #10 had been diagnosed at any time with bipolar disorder. An interview on 11/16/23 at 11:20 A.M. with MDS Coordinator #715 verified Resident #10 did not have bipolar disorder and it was coded on the MDS assessment dated [DATE] in error. 2. Review of the medical record for Resident #50 revealed an admission date of 10/18/21. Diagnoses included chronic kidney…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-16 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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 record review, resident and staff interview, and facility policy review, the facility failed to the resident's care plans were developed and reviewed with an interdisciplinary approach and failed to ensure the care plans were reviewed following the completion of the Minimum Data Set 3.0 assessments. This affected three (#14, #51, and #58) of eleven residents reviewed during the investigative process who were not recently admitted to the facility. The facility census was 69. Findings include: 1. Record review for Resident #14 revealed an admission date of 04/03/21. Diagnoses included hypertensive heart and chronic kidney disease with heart failure and stage one through stage four chronic kidney disease. Type two diabetes mellitus, iron deficiency anemia, intestinal malabsorption, and morbid obesity due to excessive calories. Review of the care plans dated 04/03/21 revealed the disciplines involved were dietary, nursing and the physician. Review of the quarterly Minimum Data Set (MDS) assessment 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-16 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, staff interview, policy review, and review of the manufacturer instructions, the facility failed to administer medications to the residents without a significant medication error. This affected one (Resident #5) of one resident observed for insulin administration. The facility census was 69. Findings include: Review of Resident #5's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included type two diabetes mellitus. Review of the physician's orders revealed Resident #5 had an order for Basalar Kwik pen U-100 insulin 100 units per milliliter (ml) administer 30 units subcutaneously twice daily. Observation of Resident #5 receiving medication on 11/15/23 at 7:16 A.M. provided by Registered Nurse (RN) # 713 revealed RN #713 prepared the Basalar Kwik pen by cleaning the stopper of the pen with an alcohol wipe, placing a disposable needle on the end of the pen, and dialed the pen to the physician ordered dose of 30 units on the pen. RN #713…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2021-08-09 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and review of facility policies, the facility failed to ensure there was a functioning thermometer in the unit refrigerators and freezers and staff were monitoring the temperature of the unit refrigerators and freezers. This affected 48 of 48 residents who potentially receive food/drinks from the unit refrigerators. The facility identified three (#21, #26, and #34) residents that receive nothing by mouth. The census was 51. Findings include: Observation on 07/28/21 at 2:07 P.M., revealed the refrigerator at the north nurse's station had a thermometer with a reading of 41 degrees Fahrenheit and no logs were posted for monitoring temperatures. Observation on 07/28/21 at 2:11 P.M., revealed the refrigerator and freezer at the south nurse's station did not contain a thermometer and no logs were posted for monitoring temperatures. Interview on 07/28/21 at 2:11 P.M., with Licensed Practical Nurse (LPN) #10 verified the refrigerator at the south nurse's station did not contain thermometers in both the refrigerator and the freezer. LPN #10 was not sure…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-08-09 · tag F0585 — failed to handle grievances — isolated
    Honor 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, missing item form review, facility communication form review, resident and staff interviews and review of facility policy, the facility failed to ensure a reported missing item was addressed timely. This affected one (#50) of two residents reviewed for missing items. The facility census was 51. Finding include: Review of the medical record for Resident #50 revealed an admission date of 10/30/17. Diagnoses included intellectual disabilities and anxiety disorder. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 was assessed as having mild cognitive impairment. Resident #50 required supervision with transfers, walking in room and corridor, locomotion on unit and off the unit, and extensive assistance of one person for dressing. Interview and observation on 07/26/21 at 2:40 P.M., with Resident #50 revealed the resident was missing a pair of black shoes and only had a pair of slippers. Resident #50 reported they are supposed to get…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-08-09 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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 record review, resident and staff interviews, observation and policy review, the facility failed to ensure care plans were revised to include an accurate dialysis schedule and smoking interventions. This affected two (#22 and #46) of 20 residents reviewed for care plans. The census was 51. Findings Include: 1. Review of the medical record for Resident #22 revealed an admission date of 04/01/20 with diagnoses including end stage renal disease, Diabetes Mellitus type two, and chronic obstructive pulmonary disease. Review of the quarterly minimum data set assessment dated [DATE] revealed Resident #22 was cognitively intact and received dialysis treatments. Review of the active physician order dated 07/08/21 revealed Resident #22 was ordered for dialysis three times per week on Tuesday, Thursday, and Saturday. Review of the Resident #22's comprehensive care plan revealed she is at risk of complications due to dialysis related to end stage renal disease with interventions including resident dialysis days are…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-08-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and staff interview, the facility failed to implement fall interventions as care planned. This affected two (#22 and #46) of four residents reviewed for falls. The census was 51. Findings Include: 1. Review of the medical record for Resident #22 revealed an admission date of 04/01/20, with diagnoses including end stage renal disease, diabetes mellitus type two, and chronic obstructive pulmonary disease. Review of the quarterly minimum data set assessment dated [DATE], revealed Resident #22 was cognitively intact and had one fall with major injury since her last assessment. Review of the comprehensive care plan revealed Resident #22 was at risk for falls and subsequent injury with interventions including Don't fall, please call sign at bedside. Observation of Resident #22 and her room on 07/28/21 at 10:48 A.M., revealed there was no Don't fall, please call sign at bedside. Interview with Director of Nursing on 07/28/21 at 10:48 A.M., verified Resident #22 was supposed to have…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-08-09 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide 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 medical record reviews, observations, and staff interviews, the facility failed to ensure the care and treatment of indwelling catheters was provided to prevent possible infections and maintained to prevent urine from leaking and exposing others to possible infections. This affected three residents (#45, #47 and #14) of five residents who had indwelling catheters. The facility census was 51. Findings include: 1. Review of Resident #45's medical record revealed an admission date of 03/23/07. Diagnoses included multiple sclerosis, presence of urogenital implants, neuromuscular dysfunction of the bladder, and retention of urine. Review of Resident #45's Minimum Data Set (MDS) assessment dated [DATE] listed the resident has having an indwelling catheter. Review of Resident #45's monthly physician orders dated July 2021 revealed the resident had an order to flush suprapubic catheter twice a day. Observation on 07/28/21 at 2:11 P.M., of Resident #45's bathroom revealed two plastic measuring devices sitting 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-08-09 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and facility policy, the facility failed to ensure oxygen was set at physician ordered liter flow. This affected two residents (#19 and #26) of nine residents who receive oxygen. The facility census was 51. Findings include: 1. Review of Resident #19's medical record revealed an admission date of 07/21/20. Diagnoses included malignant neoplasm of right bronchus, COVID-19, acute and chronic respiratory failure with hypoxia, diabetes, obstructive sleep apnea, and anxiety disorder. Review of Resident #19's Minimum Data Set (MDS) assessment dated [DATE] listed the resident as receiving oxygen. Review of Resident #19's physician order dated 07/21/20 revealed an order for oxygen per nasal cannula at three liters per minute continuously for resident comfort or oxygen saturations below 88%. Observation on 07/28/21 9:30 A.M., of Resident #19 revealed the resident's oxygen concentrator was set at 4.5 liters per minute via nasal cannula. Interview on 07/28/21…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-08-09 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and policy review, the facility failed to address pharmacist medication regimen review recommendations. This affected one (#22) of six residents reviewed for unnecessary medications. The census was 51. Findings include: Review of the medical record for Resident #22 revealed an admission date of 04/01/20, with diagnoses including end stage renal disease, diabetes mellitus type two, and chronic obstructive pulmonary disease. Review of the quarterly minimum data set assessment dated [DATE] revealed Resident #22 was cognitively intact. Review of the Resident #22's pharmacist drug regimen review dated 06/11/21 revealed the pharmacist documented for the facility to please take the following action and see the report. Interview with Director of Nursing on 07/29/21 at 2:30 P.M. revealed she did not know if Resident #22 had any pharmacist recommendations for June 2021 and the facility did not have a copy of any pharmacist recommendations for June 2021. No pharmacist recommendations…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2025-01-30 · tag F0607 — failed to have anti-abuse policies — widespread
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, staff interview, and policy review, the facility failed to follow its abuse prevention policy by not completing reference checks for five out of five newly hired personnel reviewed. This failure had the potential to affect all 62 residents in the facility. The facility census was 62. Findings include: Review of the personnel file for Registered Nurse (RN) #80 revealed a hire date of 06/21/24. The reference check form for RN #80 contained her name, position, and signature dated 06/20/24; however, it lacked any documentation of previous work history or confirmation that a reference check had been completed. Review of the personnel file for RN #85 revealed a hire date of 02/06/24. The reference check form for RN #85 contained only a signature dated 02/06/24, with no evidence of previous work history or documentation confirming a reference check was completed. Review of the personnel file for Certified Nursing Assistant (CNA) #62 revealed a hire date of 05/15/24. There was no documentation indicating a reference check had been completed or initiated. Review 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has plan of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to ATRIUM CENTERS — 26 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 53.0≈ chain avg
Health inspection 3 of 52.7+0.3 vs chain
Staffing 3 of 53.4-0.4 vs chain
Quality measures 4 of 53.7+0.3 vs chain
The other 25 homes this chain runs (chain average 3.0★, per CMS)
1 of 5Marshall Nursing and Rehabilitation CommunityMarshall, MI 1 of 5Mulder Health Care FacilityWest Salem, WI 1 of 5Riverside Nursing CentreGrand Haven, MI 2 of 5Allendale Nursing and Rehabilitation CommunityAllendale, MI 2 of 5Plainwell Pines Nursing and Rehabilitation CommuniPlainwell, MI 2 of 5Roosevelt Park Nursing and Rehabilitation CommunitMuskegon, MI 2 of 5South Haven Nursing and Rehabilitation CommunitySouth Haven, MI 2 of 5The Timbers of Cass CountyDowagiac, MI 2 of 5Tomah Nursing And RehabTomah, WI 2 of 5Westgate Nursing & Rehabilitation CommunityIronwood, MI 3 of 5Austinburg Nsg And Rehab CtrAustinburg, OH 3 of 5Crittenden County Health & Rehabilitation CenterMarion, KY 3 of 5Frederic Nursing And Rehab CommunityFrederic, WI 3 of 5Lincoln Haven Nursing & Rehabilitation CommunityLincoln, MI 3 of 5Prescott Nursing And Rehab CommunityPrescott, WI 3 of 5Salem Springlake Health & Rehabilitation CenterSalem, KY 4 of 5Blossom Nursing And Rehab CenterSalem, OH 4 of 5Fairview Nursing and Rehabilitation CommunityCentreville, MI 4 of 5Gladwin Nursing and Rehabilitation CommunityGladwin, MI 4 of 5Grayling Nursing & Rehabilitation CommunityGrayling, MI 4 of 5Heritage Nursing and Rehabilitation CommunityZeeland, MI 4 of 5Lexington Court Care CenterLexington, OH 5 of 5Freeman Nursing & Rehabilitation CommunityKingsford, MI 5 of 5Hillcrest Nursing and Rehabilitation CommunityNorth Muskegon, MI 5 of 5King Nursing & Rehabilitation CommunityHoughton Lake, MI

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 / managerTypeRoleShareSince
ORION OPERATING SERVICES LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL100%since 09/08/2006
FIFTH THIRD BANKOrganization5% OR GREATER MORTGAGE INTEREST; OPERATIONAL/MANAGERIAL CONTROLsince 03/07/2017
HELLER, DAVIDIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/18/2024
JOHNSON, CINDYIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/18/2024
ATRIUM CENTERS MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/18/2024
ALBRIGHT ROSS, SUSANIndividualOPERATIONAL/MANAGERIAL CONTROL; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 01/02/2018
ANDERSON, CURTIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/01/2025
CHERRY, JILLIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2025
FREUNDLICH, THOMASIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2025
MORRIS, AMANDAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/05/2023
TAYLOR, AMANDAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/10/2025
AMICUS CAPITAL HOLDINGS INCOrganizationADP OF THE SNFsince 08/18/2021
AMICUS CAPITAL HOLDINGS, INC. EMPLOYEE STOCK OWNERSHIP TRUSTOrganizationADP OF THE SNFsince 08/18/2021
AMICUS PROPERTIES LLCOrganizationADP OF THE SNFsince 01/01/2021
BROAD RIVER REHABILITATIONOrganizationADP OF THE SNFsince 09/01/2021
FORVIS MAZARS LLPOrganizationADP OF THE SNFsince 06/01/2023
LEADERSTAT LTDOrganizationADP OF THE SNFsince 01/01/2025
OCS REAL ESTATE HOLDINGS LLCOrganizationADP OF THE SNFsince 01/01/2021
OMNICARE LLCOrganizationADP OF THE SNFsince 01/01/2025
ORION PROPERTIES SIX ALPHA LLCOrganizationADP OF THE SNFsince 08/29/2025
PLANTE & MORAN PLLCOrganizationADP OF THE SNFsince 01/01/2025
PAREDES, MIGUELIndividualADP OF THE SNFsince 08/18/2021

CMS files one row per role, so the 35 rows in the source record cover these 22 parties — each is shown once here with every role it holds. Nothing is omitted.

13 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.

$6.9M
Net patient revenuemost recent cost report
-0.4%
Operating marginrevenue minus expenses
$1.4M
Related-party expense21% of expenses
Who pays — share of resident-days
Medicaid 57%Medicare 9%Other / private 34%

This home reported $1.4M 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.

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

$290per resident / day
operating cost
$8,825per month
≈ monthly operating cost
$289per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in OH

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Ohio Medicaid page.

Typical monthly cost in Ohio
$9,186/mo
Nursing home (semi-private)
$10,389/mo
Nursing home (private)
$6,103/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 366028. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-01-30, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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