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Whispering Hills Rehabilitation And Nursing Center

416 Wooster Road, Mount Vernon, OH 43050 · For profit - Limited Liability company · 44 certified beds · (740) 397-9626 Medicare & Medicaid certified

Call the home — (740) 397-9626 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0610) — cited Nov 2022
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

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 a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (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 (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 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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
855 Coshocton Ave # H · (740) 326-6552 · Call to confirm hours
Pharmacy
69 Sychar Rd · (740) 397-0145 · Call to confirm hours
Grocery
105 S Main St · (740) 392-6142 · Call to confirm hours
Park
100 Sychar Rd · (740) 393-9501 · Typically dawn to dusk
Place of worship
221 Sychar Rd

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 2 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.

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 increased1.8%5.3%15.4%better than state — see note marked double-dagger below the table
Long-stay residents who lose too much weight7.9%6.2%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.2%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection2.3%0.4%2.0%worse than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms30.5%30.1%6.5%typical for the 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 injury3.1%3.2%3.3%typical
Long-stay residents whose ability to walk worsened3.3%6.1%16.1%better than state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication25.2%25.5%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%94.5%95.3%typical
Long-stay residents with pressure ulcers6.5%3.4%4.7%worse
Long-stay residents with worsening bladder/bowel control16.4%21.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table8.5%8.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine96.8%75.6%79.4%better
Long-stay hospitalizations per 1,000 resident days1.031.731.67better
Long-stay outpatient ER visits per 1,000 resident days1.341.801.80better

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.

11.2%U.S. median 10.7%
Went back to hospital
0.19U.S. median 0.31
Therapy hours / resident / day
0.05hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.19 therapist hours per resident per day in 2026Q1 — more than 20% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 21% 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 SNFnot 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 SNF11.2%CMS range 7.3–16.310.7%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 identifiednot 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 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 staynot 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 worsenednot 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 hospitalizationnot 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 SNFs1.101.02Oct 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

0.59
RN hours/ resident / day
0.76
LPN hours/ resident / day
1.62
Aide hours/ resident / day
2.97
Total nurse hours/ resident / day
0.50
RN hoursweekends
47.1%
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 44 beds and averages 39.7 residents a day — about 90% occupied, or roughly 4 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 2.97 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.59 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.62 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 2.76 hrs/resident/day on weekends vs 3.06 on weekdays — 10% thinner on weekends. RN hours go from 0.63 to 0.50 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 47% is about the same as the national median of 45%.

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

Inspection trend

9
deficiencies at the latest standard inspection (2026-02-19)
9
at the previous standard inspection (2024-11-21)

Deficiencies are unchanged from the previous inspection. 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.

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 · D2026-02-19 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure Resident #13 and #44 received a written bed hold authorization letters and the Ombudsman was notified of all hospitalization and discharges. This affected two residents (Resident #13 and #44) of three residents reviewed for discharge planning. The facility census was 38.Findings Include: 1. Review of Resident #44 ' s medical record revealed admission date 01/05/26 and a discharge to the hospital on [DATE] with diagnoses including but not limited to chronic obstructive pulmonary disease, unspecified sequelae of cerebral infarction, dysphagia, hypertension, anxiety disorder and depression. Review of Resident #44 ' s admission Minimum Data Set (MDS) dated [DATE] revealed Resident #13 was cognitively intact with a Brief Interview Mental Status (BIMS) score of 14 out a possible 15 and required staff assistance with Activities of Daily Living (ADL) tasks. Further review revealed Resident #44 was his own representative and had a family member as an…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-19 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview and facility policy review the facility failed to assist a dependent resident with fingernail care. This deficient practice affected one resident (Resident #3) out of two residents reviewed for Activities of Daily Living. The facility census was 38.Findings Include: Review of Resident #3's medical record revealed admission date 08/04/25 with diagnoses including but not limited to respiratory failure, type two Diabetes, depression, history of stroke and vascular dementia.Review of Resident #3's self-care deficit care plan dated 08/05/25 revealed Resident #3 required encouragement and assistance from staff to complete self-care tasks.Review of Resident #3's Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #3 had impaired cognition with a Brief Interview Mental Status (BIMS) score of 11 out of possible 15, used a wheelchair for mobility, and was dependent on staff for the completion of personal hygiene tasks.Review of Resident #3's shower documentation…

    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 · D2026-02-19 · tag F0685 — isolated
    Assist a resident in gaining access to vision and hearing services.
    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 Resident #18 had audiology follow up completed. This affected one (#18) of one residents reviewed for hearing or vision concerns. The census was 38. Findings include:Record review for Resident #18 revealed an admission date of 05/16/25. Diagnoses include type II diabetes without complications, essential (primary) hypertension, peripheral vascular disease, acquired absence of right leg above knee, plasma cell leukemia having not achieved remission, solitary plasmacytoma not having achieved remission, need for assistance with personal care, adjustment disorder with mixed anxiety and depressed mood, and bilateral hypertensive retinopathy.Review of Resident #18's 360 care Audiology appointment dated 09/29/25 9:30 A.M. exam revealed Resident #18 was referred by the facility due to decreased hearing. A otoscopy was completed and it revealed impacted cerumen of both ears. Debrox (ear wax softener used to help remove wax from the ears) was recommended for cerumen management. Follow up noted as cerumen…

    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 · D2026-02-19 · 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 observation, record review, interview and policy review the facility failed to ensure appropriate trach care was provided. This affected one resident (Resident #34) of one residents observed for trach care.Findings Include: Review of the medical record for Resident #34 revealed an admission date 02/10/26 with diagnosis including but not limited to malignant neoplasm of tongue, protein-calorie malnutrition, dysphagia, and anxiety. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #34 had intact cognition and required tracheostomy (trach) care daily. Review of the physician orders dated 02/10/26 revealed trach care per protocol and speaking/[NAME] Muir valve to trach, as tolerated cuff must be deflated on trach prior to placement of speaking valve.Observation on 02/19/26 at 1:35 P.M. of Resident #34's trach care with Registered Nurse (RN) #315 revealed during trach care RN #315 removed the speaking valve off the trach and placed it on the bed side table. RN #315 suctioned Resident #34…

    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 · D2026-02-19 · 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 and interview, the facility failed to ensure Resident #20 received antipsychotic medication as scheduled and per the resident's routine dose resulting in a significant medication error. This affected one (Resident #20) out of six residents reviewed for medications. The facility census was 38. Findings include: Review of the medical record revealed Resident #20 was admitted on [DATE] with diagnoses that included schizoaffective disorder bipolar type, borderline intellectual functioning, and Asperger's syndrome. A care plan dated 02/05/24 revealed Resident #20 required psychotropic/mood stabilizer medications for behavior management. Interventions included to administer psychotropic/mood stabilizer medications as ordered. A care plan dated 02/09/24 revealed Resident #20 had behavior problems with interventions that included to administer medications as ordered. A psychiatric note dated 10/01/25 revealed Resident #20 received Invega Sustenna (atypical antipsychotic) 156 milligram/milliliter…

    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 · D2026-02-19 · tag F0825 — isolated
    Provide or get specialized rehabilitative services as required for a 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 staff interviews, the facility failed to provide required specialized rehabilitative services (speech therapy) for one of one residents reviewed (Resident #17) who was identified as needing further swallowing assessment. Findings include: Review of the medical record revealed Resident #17 was admitted on [DATE] with diagnoses including dysphagia, traumatic brain injury, schizophrenia, major depressive disorder, type II diabetes mellitus, and other chronic medical conditions.Review of the comprehensive Minimum Data Set (MDS) dated [DATE] reflected cognitive impairment.Review of the Registered Dietitian (RD #316) Weight Review dated 02/19/2026 revealed Resident #17 experienced significant weight loss. The RD documented the resident recently had teeth extracted and requested a Speech-Language Pathology (SLP) evaluation to assess swallowing function and determine if the current diet order remained appropriate. Review of physician orders and therapy documentation revealed no evidence that…

    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 · D2026-02-19 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review the facility failed to ensure Resident #34 and Resident #37 had complete and accurate medical records. This affected 2 of 16 medical records reviewed. The census was 38. Finding include: Record review of Resident #34's medical record revealed an admission date of 02/10/26. Diagnoses include malignant neoplasm of tongue and mouth, dysphagia, and tracheostomy status. Review of Resident #34's comprehensive The Minimum Data Set (MDS) 3.0 dated 02/17/26 revealed a Brief Interview for Mental Status (BIMS) score of 15. Record review of Resident #34's medical record revealed an active physician order for Nothing by Mouth (NPO) diet Nothing by Mouth texture, nothing by mouth consistency dated 02/10/26. Review of Resident #34's medical record revealed a care plan stating Resident #34 has an alteration in neurological status related to dysphagia. Goals include being able to function at the fullest potential possible as outlined by the interdisciplinary team, will…

    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 · D2026-02-19 · tag F0880 — failed to prevent and control infections — isolated
    Provide 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, record review, and policy review, the facility failed to ensure infection control procedures were followed during a dressing change for Resident #4. This affected one (Resident #4) out of two residents with percutaneous endoscopic gastrostomy (PEG) tubes. The facility census was 38. Findings include: Review of the medical record revealed Resident #4 was admitted on [DATE] with diagnoses that included Parkinson's disease, dementia associated with Parkinson's disease, muscle weakness, contractures, dysphagia, and recurrent urinary tract infections. A physician order dated 04/01/22 revealed Resident #4's peg tube site was to be cleansed with wound wash, patted dry, and a split gauze placed every shift. A plan of care dated 11/04/25 revealed Resident #4 required tube feeding due to dysphagia, swallowing problems, and malnutrition. Interventions included enhanced barrier precautions, and the head of the bed to be elevated greater than 30 degrees during and after tube feeding. 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-19 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to follow the antibiotic stewardship guidelines. Resident #37 was ordered antibiotics prior to the culture and sensitivity results being obtained. This affected one (Resident #37) out of six residents reviewed for unnecessary medications. The facility census was 38. Findings include: Review of the medical record revealed Resident #37 was admitted on [DATE] with diagnoses that included fracture of sacrum, major depressive disorder, adjustment disorder with anxiety, obstructive and reflux uropathy, and benign prostatic hyperplasia without urinary tract symptoms. Review of the December infection control log revealed Resident #37 had a urinary tract infection with an onset date of 12/31/25. Resident #37 was ordered Macrobid (antibiotic) and infection was resolved on 01/02/26. The January infection control log revealed Resident #37 had a urinary tract infection with an onset date of 12/31/25. Resident #37 was ordered Levofloxacin (antibiotic),…

    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 · F2024-11-21 · tag F0847 — widespread
    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

    Based on record review, review of the facility arbitration agreement, and staff interview, the facility failed to ensure their arbitration agreement had the required information that the signing resident or resident representative may communicate with federal, state, or local officials, including but not limited to, federal and state surveyors, other federal or state health department employees, and representative of the Office of the State Long-Term Care Ombudsman as well as the agreement stated that the if the resident or resident representative would wish to cancel the arbitration agreement in within thirty (30) days, it does not have to be in writing. This affected 37 of 38 residents who signed the arbitration agreement. Resident #3 did not sign the arbitration agreement upon admission. The facility census was 38. Findings include: Review of the facility's admission packet revealed an arbitration agreement was within the admission packet. Review of resident medical records during the survey revealed arbitration agreements were signed by residents with the exception 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.

    Administration Deficiencies · Deficient, Provider has date of correction
Show the remaining 18 citations
  • Potential for harm · F2024-11-21 · tag F0848 — widespread
    Provide a neutral and fair arbitration process and agree to arbitrator and venue.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, record review, and review of facility arbitration agreement, the facility failed to provide a neutral and fair arbitration process by ensuring both the resident or his or her representative, and the facility agree on the selection of a neutral arbitrator, and that the venue is convenient to both parties. This affected 37 of 38 residents who signed the arbitration agreement. Resident #3 did not sign the arbitration agreement upon admission. The facility census was 38. Findings include: Review of the facility's admission packet revealed an arbitration agreement was within the admission packet. Review of resident medical records during the survey revealed arbitration agreements were signed by residents with the exception of the agreement for Resident #3, which was not signed upon admission. Review of the facility's arbitration agreement revealed that by signing this Agreement, the Parties agree that, except as otherwise set forth herein, any action, claim, dispute or controversy of any kind, whether in contract, tort, statutory, common law, legal, equitable,…

    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 · F2024-11-21 · tag F0949 — failed to train staff on dementia and abuse — widespread
    Provide behavior health training consistent with the requirements and as determined by a facility assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility assessment, personnel record review, and staff interview, the facility failed to provide behavioral health education to all staff in orientation and annually thereafter. This had the potential to affect all 38 residents residing in the facility. Findings include: Review of the facility assessment dated [DATE] revealed the facility accepted residents with psychiatric disorders to include impaired cognition, mental disorder, bipolar, schizophrenia, post-traumatic stress disorder, anxiety disorder, and behaviors which required interventions. Review of the personnel file for Dietary Aide #500 revealed a hire date of 07/24/24 and no evidence the employee received training on mental health behaviors. Review of the personnel file for Housekeeper #209 revealed a hire date of 09/16/24 and no evidence the employee received training on mental health behaviors. Review of the personnel file for License Practical Nurse (LPN) #213 revealed a hire date of 07/24/24 and no evidence the employee…

    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 · E2024-11-21 · tag F0805 — failed to prepare food in a form residents can eat — pattern
    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

    Based on observation, staff interview, test tray, and record review, the facility failed to serve pureed foods at a smooth consistency for residents on a mechanically altered diet. This had the potential to affect four residents (#4, #5, #23, and #30) identified by the facility who were prescribed pureed diets. The facility census was 38. Findings include: The observation of puree preparation on 11/18/24 at 10:50 A.M. revealed Dietary Manager (DM) #200 changed the puree vegetable for lunch to pureed peas. She stated the squash in the mixed vegetables sometimes does not puree correctly to a smooth consistency because of the rind. [NAME] #241 pureed the peas for several minutes and was tasting the peas as she was going. She took the pureed peas out of the robot coupe container, put the pureed peas into bowls for the residents, portioned a small amount into a five-ounce dessert dish with a plastic spoon. The taste test on 11/18/24 at 10:50 A.M. revealed the pureed peas were not of a smooth consistency and had pieces of the pea shells in it. The Regional Director of Culinary (RDC) #251…

    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 · D2024-11-21 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of 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 observation, record review, and resident and staff interview, the facility failed to ensure Resident #141 was aware of the location and how to use the bathroom call light. This affected one (#141) of 19 residents reviewed in the initial sample of the annual survey. The facility census was 38. Findings include: Record review revealed Resident #141 was admitted to the facility on [DATE] with diagnoses including necrotizing fasciitis, Fournier gangrene, and diabetes mellitus. The admission Minimum Data Set (MDS) 3.0 assessment was in progress. Review of the care plan dated 11/12/24 revealed Resident #141 had a potential risk for falls related to weakness from hospital stay for necrotizing fasciitis labia majora and groin with Fournier gangrene with surgical debridement. Interventions included but not limited to call light within reach. An interview on 11/18/24 at 9:40 A.M. with Resident #141 revealed she felt unsafe in the bathroom because there was no call light in it. Observation and interview 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-21 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately 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 resident, staff, and physician interview, record review, policy review, and Standard of Care by the American Diabetic Association, the facility failed to ensure Resident #39's representative was timely notified following a change in condition and failed to ensure Resident #21's physician was notified timely following a new diagnosis of diabetes mellitus. This affected two (Residents #21 and #39) of two residents reviewed for change of condition. The facility census was 38. Findings include: 1. Record review for Resident #39 revealed an admission date of 03/07/24 and a discharge date of 08/30/24. Diagnoses included chromic obstructive pulmonary disease, chronic kidney disease, psychoactive substance abuse, and paranoid schizophrenia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 was cognitively intact and was independent for activities of daily living. Review of the progress note for Resident #39 dated 08/30/24 at 9:36 A.M. revealed Resident #39 was sitting…

    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 · D2024-11-21 · tag F0622 — isolated
    Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure documentation was completed and physician notification occurred prior to a hospitalization for Resident #29. This affected one (#29) of two residents reviewed for hospitalization. The facility census was 38. Findings include: Record review for Resident #29 revealed an admission date of 07/27/21. Diagnosed included diabetes mellitus, chronic kidney disease, and malignant neoplasm of duodenum. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 was cognitively intact and required set up assistance for activities of daily living. Review of the progress note for Resident #29 dated 11/17/24 at 12:10 P.M. revealed Resident #29 requested to go to emergency room (ER) due to stomach being bloated. There were no signs and symptoms of clostridioides difficile (C-diff). Resident on Augmentin (antibiotic) for urinary tract infection (UTI). The husband was at bedside. Emergency services (911) called with report.…

    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 · D2024-11-21 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    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, staff, and physician interview, review of the Older Adults: Standard of Care in Diabetes-2024 by the American Diabetes Association, and policy and procedure for Nursing Care of the Resident with Diabetes Mellitus, the facility failed to provide diabetic care in accordance with professional standards after a diagnosis of type II diabetes mellitus was added to Resident #21's diagnoses. This affected one (#21) of 18 residents reviewed for standards of care. The facility census was 38. Findings include: Review of the medical record revealed Resident #21 was admitted on [DATE] and readmitted on [DATE] with diagnoses including traumatic brain injury, type II diabetes mellitus (DM), and acute respiratory failure. Review of the hospital notes dated 05/27/24 revealed Resident #21 had a history of traumatic brain injury in January 2022, intracerebral hemorrhage, seizure disorder, mood disorder, DM, and encephalopathy. The summary of hospitalization did not reveal diagnosis of DM or use 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-21 · 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, policy review, and staff interview, the facility failed to identify if the pharmacy had any irregularities or recommendations from June 2024 through October 2024. This affected three (Resident #10, #29, and #33) of five residents reviewed for unnecessary medications. The facility census was 38. Findings include: 1. Review of the medical record revealed Resident #10 was admitted on [DATE] with diagnoses that included Fourier gangrene, paralytic, neuromuscular dysfunction, colostomy, bipolar disorder, convulsions, anxiety disorder, and major depressive disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was cognitively intact. Resident #10 received antianxiety, antidepressant, anticoagulant, and opioid medications. The physician orders included Effexor (antidepressant), Percocet (opioid pain medication) hydroxyzine (to treat anxiety), Keppra (anticonvulsant), apixaban (anticoagulant), amantadine (antidyskinetic), and paliperidone (antipsychotic)…

    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 · F2022-11-09 · tag F0868 — widespread
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and staff interview, the facility failed to ensure Quality Assessment and Assurance (QAA) committee meetings were conducted quarterly. This had the potential to affect all 42 residents in the facility. Findings Include: Review of the facility QAA committee meeting minutes revealed the most recent QAA Committee meetings were 01/26/22 and 02/23/22. There were no further quarterly meetings completed for 2022. Interview on 11/09/22 at 1:02 P.M. with Administrator confirmed the last QAA committee meeting was January and February of 2022 and they had not had a meeting since.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2022-11-09 · tag F0947 — failed to train nurse aides adequately — widespread
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to provide State Tested Nurses Aides (STNA) 12 hours of continuing competency training a year. This affected all 42 residents who reside in the facility. Findings include: Review of the personal files revealed: 1. STNA #97 was hired on 09/25/18, but had not received 12 hours of yearly competency training, including dementia management, providing services for cognitively impaired individuals, or mental health education. 2. STNA #92 was hired on 08/11/21, but had not received 12 hours of yearly competency training, including dementia management, providing services for cognitively impaired individuals, or mental health education. 3. STNA #96 hired on 10/29/20, but had not received 12 hours of yearly competency training including, dementia management, providing services for cognitively impaired individuals, or mental health education Interview on 11/09/22 at 12:14 P.M. with Administrator confirmed the facility had not been doing annual training on dementia management, cognitive impairments, or mental health. She verified 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-11-09 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, facility investigative documents, and facility policy review, the facility failed to thoroughly investigate all potential abuse allegations. This affected two (Residents #27 and #36) of two residents reviewed for abuse. Findings Include: 1. Resident #27 was admitted to the facility on [DATE]. His diagnoses were encounter for orthopedic aftercare following surgical amputation, diabetes, type II diabetes, moderate protein calorie malnutrition, acute kidney failure, bipolar disorder, post traumatic stress disorder, anxiety disorder, anemia, major depressive disorder, and schizoaffective disorder. Review of Resident #27 progress notes, dated 06/03/22, revealed he was involved in a physical altercation with a known community member. This physical altercation resulted in an injury to Resident #27 and needed evaluation/treatment at the hospital. Review of facility Self Reported Incident (SRI) number 222408, dated 06/04/22, confirmed the incident that occurred 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-11-09 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and facility policy review, the facility failed to notify the state long term care ombudsman of discharges. This affected one (Resident #42) of two resident discharges reviewed. Findings Include: Resident #42 was admitted to the facility on [DATE]. Her diagnoses were acute respiratory failure with hypoxia, multiple sclerosis, type II diabetes, hypertension, anxiety disorder, major depressive disorder, neuropathy, hyperlipidemia, and osteoarthritis. Review of her Minimum Data Set (MDS) assessment, dated 08/01/22, revealed she was cognitively intact. Review of Resident #42 medical records revealed she was discharged from the facility to the hospital on [DATE]. Review of all her medical records reveal no documentation to support the facility notified the state long term care ombudsman's office of this discharge as required. Interview with Administrator on 11/09/22 at 11:40 A.M. confirmed they have no evidence they contacted the state long term care ombudsman when…

    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 · D2022-11-09 · 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 medical record review, staff interview, and facility policy review, the facility failed to provide a bed hold notice at the time of discharge to the hospital. This affected one (Resident #42) of two resident discharges reviewed. Findings Include: Resident #42 was admitted to the facility on [DATE]. Her diagnoses were acute respiratory failure with hypoxia, multiple sclerosis, type II diabetes, hypertension, anxiety disorder, major depressive disorder, neuropathy, hyperlipidemia, and osteoarthritis. Review of her Minimum Data Set (MDS) assessment, dated 08/01/22, revealed she was cognitively intact. Review of Resident #42 medical records revealed she was discharged from the facility to the hospital on [DATE]. Review of all her medical records reveal no documentation to support the provided a bed hold notification at the time of hospital discharge as required. Interview with Administrator on 11/09/22 at 11:40 A.M. confirmed they have no evidence they provided a bed hold notification when Resident #42 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-11-09 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 and staff interview, the facility failed to ensure all resident Pre-admission Screening and Resident Review (PASRR) documents were accurate to resident current conditions and diagnoses. This affected two (Resident #20 and Resident #27) of three residents reviewed for PASRR. Findings Include: 1. Resident #20 was admitted to the facility on [DATE]. Her diagnoses were chronic respiratory failure, asthma, chronic obstructive pulmonary disease, osteoarthritis, heart failure, anemia, hypertension, congestive heart failure, anxiety disorder, panic disorder, psychosis, psychotic disorder with delusions, major depressive disorder, and sciatica. Review of Resident #20 PASRR document, dated 12/08/20, revealed under Section D, the diagnoses listed were mood disorder, panic or other severe anxiety disorder, depression, and insomnia. Review of her diagnoses list, she also had the following diagnoses that should have been indicated/updated on her PASRR document: unspecified psychosis, which 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 · D2022-11-09 · tag F0646 — isolated
    Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
    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 and staff interview, the facility failed to ensure all significant mental health changes were communicated to the state mental health agency. This affected two (Resident #20 and Resident #27) of three residents reviewed for PASRR. Findings Include: 1. Resident #20 was admitted to the facility on [DATE]. Her diagnoses were chronic respiratory failure, asthma, chronic obstructive pulmonary disease, osteoarthritis, heart failure, anemia, hypertension, congestive heart failure, anxiety disorder, panic disorder, psychosis, psychotic disorder with delusions, major depressive disorder, and sciatica. Review of Resident #20 PASRR document, dated 12/08/20, revealed under Section D, the diagnoses listed were mood disorder, panic or other severe anxiety disorder, depression, and insomnia. But review of her diagnoses list, she also had the following diagnoses that should have been indicated/updated on her PASRR document: unspecified psychosis, which was added on 07/27/22, and psychotic…

    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 · D2022-11-09 · 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

    Based on interview, record review and policy review, the facility failed to ensure Resident #1's falls were thoroughly investigated and new interventions were implemented to prevent falls. This affected one resident (Resident #1) out of one residents reviewed for falls. Findings include: Review of Resident #1's medical record revealed an admission date of 04/15/21 with diagnoses including dementia, altered mental status, muscle weakness, and cogitative communication deficit. Review of Resident #1 care plan revealed the resident was at risk for falls related to weakness, deconditioning, unsteady gait, and recent falls. Interventions which were all dated 04/15/21 and included, ensure non skid footwear, bed in lowest position, keep call light within reach, keep frequently used items within reach, and keep room free of clutter. Review of Resident #1's fall investigation information, dated 07/22/22, revealed the resident was found on the floor and was lifted to bed using the hoyer lift. The investigation did not examine how, where, or why the resident fell. The facility did not put in…

    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 · Dcited before2022-11-09 · 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 medical record review, interview, and policy and procedure review, the facility failed to ensure Resident #27's medications were reviewed monthly by a pharmacist and failed to ensure Resident #20 and Resident #21's pharmacy recommendations were timely addressed with appropriate rationale for action taken. This affected three residents (Resident #20, #21 and #27) out of five residents reviewed for unnecessary medications. Findings include: 1. Review of medical record for Resident #27 revealed readmission date of 02/21/22 with no cognitive deficits. The resident was admitted with diagnoses including right leg below amputation, acute kidney failure, bipolar and post traumatic stress syndrome. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was independent with activities of daily living Review of Resident #27 electronic medical record revealed the pharmacist reviewed his medications on 03/29/22 and 4/29/22. Review of Resident #27 paper chart revealed the pharmacist…

    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 · D2022-11-09 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review and policy review, the facility failed to ensure Resident #243 was monitored while receiving anticoagulant (blood thinning) medication. This affected one resident (Resident #243) out of five residents reviewed for medication monitoring. Findings include: Review of Resident #243's medical record revealed an admission date of 10/31/22 with diagnoses including chronic atrial tribulation, chronic kidney disease, and hypertension. Review of Resident #243's November 2022 physician orders revealed an order for Apiarian (anticoagulant) 5 milligrams (mg) by mouth two times daily for atrial tribulation. Review of Resident #243's care plan, dated 11/01/22, revealed the resident is ask risk for bleeding related to anticoagulant therapy. Interventions included for the facility to monitor the resident for increased bruising and monitor for signs and symptoms of bleeding. Continued review of the resident's medical record revealed there was no documentation showing the monitoring being done. Interview on 11/08/22 at 3:02 P.M. the Director of Nursing confirmed…

    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

“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 GARDEN HEALTHCARE GROUP — 6 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 4 of 52.5+1.5 vs chain
Health inspection 3 of 52.0+1.0 vs chain
Staffing 2 of 51.2+0.8 vs chain
Quality measures 5 of 54.8+0.2 vs chain
The other 5 homes this chain runs (chain average 2.5★, 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 / managerTypeRoleShareSince
DREIFUS, ETHANIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST8%since 09/18/2017
COHOLICH, ROBERTIndividualW-2 MANAGING EMPLOYEEsince 09/18/2017
BRAUNSTEIN, BARRYIndividualCORPORATE OFFICERsince 09/18/2017
FEUER, SAMUELIndividualCORPORATE OFFICERsince 09/18/2017
KATZ, LARRYIndividualCORPORATE OFFICERsince 09/18/2017
LAHASKY, EPHRAMIndividualCORPORATE OFFICERsince 09/18/2017
LESHKOWITZ, ELIIndividualCORPORATE OFFICERsince 09/18/2017
NORTHWOOD HEALTHCARE GROUP LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 09/18/2017

1 organizational owner 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.

$4.5M
Net patient revenuemost recent cost report
+21.9%
Operating marginrevenue minus expenses
$94K
Related-party expense3% of expenses
Who pays — share of resident-days
Medicaid 65%Medicare 14%Other / private 21%

This home reported $94K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

$252per resident / day
operating cost
$7,655per month
≈ monthly operating cost
$323per 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 366014. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-19, 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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