Lutheran Home
1036 South Perry Street, Napoleon, OH 43545 · Non profit - Corporation · 27 certified beds · (419) 592-1688 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- 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
- it has a citation for mishandling residents’ money or property (F0567)
- a high number of inspection citations overall (41) — 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
- nursing-staff turnover (77%) runs well above the national median (45%)
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 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
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 3.7% | 5.3% | 15.4% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 7.2% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.2% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.9% | 0.4% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.0% | 30.1% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.5% | 3.2% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 11.2% | 6.1% | 16.1% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 36.1% | 25.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 92.5% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.7% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 29.4% | 21.4% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 4.3% | 8.8% | 17.1% | better |
| Short-stay residents given the seasonal flu vaccine | 76.2% | 75.6% | 79.4% | typical |
| Long-stay hospitalizations per 1,000 resident days | 2.12 | 1.73 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 3.61 | 1.80 | 1.80 | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
55.3% 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 54 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.34 therapist hours per resident per day in 2026Q1 — more than 58% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 20% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 55.3%CMS range 43.5–66.9 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.5%CMS range 7.9–16.3 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.8%CMS range 3.9–13.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.05 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 27 beds and averages 25.0 residents a day — about 93% occupied, or roughly 2 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 3.82 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.75 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.46 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.77 hrs/resident/day on weekends vs 3.84 on weekdays — 2% thinner on weekends. RN hours go from 0.83 to 0.56 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 77% is well above the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
41 citations, most serious first. The 10 most serious are shown; the remaining 31 are one tap away and print in full.
- Potential for harm · F2024-09-05 · tag F0803 — failed to meet residents' dietary needs — widespreadEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, and review of the menu spreadsheets, the facility failed to ensure residents received proper portions of protein and vegetables. This affected all 46 residents in the facility who receive food from the kitchen. Additionally, the facility failed to ensure residents on a pureed diet received proper portions of carbohydrate. This affected six (#2, #7, #19, #20, #32, and #36) residents identified on a pureed diet. The facility census was 46. Findings include: 1. Observation on 09/04/24 at 11:45 A.M. revealed [NAME] #157 taking temperatures of noon menu items. The chicken Philly sandwiches were already prepared with chicken, onion, and peppers portioned into the bun. Concurrent interview with [NAME] #157 stated another staff prepared the sandwiches. Interview on 09/04/24 at 11:52 A.M. with Dietary Manager (DM) #183 revealed the facility used an outside company to provide menus and spreadsheets. DM #183 stated the facility began with a new company in May 2024 and the new menus did not provide portion sizes on the spreadsheets; therefore, DM #183 did…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-05 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately for oxygen use and upon discharge. This affected three (#15, #18, and #199) of 17 residents reviewed for MDS assessments. The facility census was 46. Findings include: 1. Review of the medical record for Resident #18 revealed an admission date of 05/30/24 with diagnosis including chronic obstructive pulmonary disease (COPD). Review of a physician order initiated 05/30/24 and discontinued 06/04/24 revealed Resident #18 was to receive oxygen therapy at two to four liters per minute (LPM) via nasal cannula (NC) every shift. The physician order initiated 06/04/24 and discontinued 08/05/24 revealed Resident #18 was to receive oxygen therapy at two to four LPM via NC every shift. Review of the comprehensive MDS admission assessment dated [DATE] revealed Resident #18 did not receive oxygen therapy. Interview on 09/04/24 at 3:32 P.M. with MDS Coordinator #184 confirmed the MDS assessment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-09-05 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and review of the facility policy, the facility failed to ensure a baseline care plan reflected a resident's use of oxygen needs. This affected one (#199) of one resident reviewed for a baseline care plan. The facility census was 46. Findings include: Review of the medical record for Resident #199 revealed he was admitted on [DATE], discharged to the hospital on [DATE], and returned to facility on 08/29/24. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 08/23/24, revealed Resident #199 had impaired cognition. Review of a physician order dated 08/29/24 revealed Resident #199 received oxygen at six liters per minute (LPM) via nasal cannula (NC) every shift. Review of the baseline care plan for Resident #199 revealed nothing regarding his reliance on continuous oxygen therapy. Interview on 09/05/24 at 11:31 A.M. with the Director of Nursing (DON) confirmed Resident #199's baseline care plan did not reflect his need for oxygen. Review of the policy…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-09-05 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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, family and staff interviews, and review of the facility policy, the facility failed to ensure oxygen was administered per physician order. This affected two (#18 and #199) of two residents reviewed for oxygen use. The facility census was 46. Findings include: 1. Review of the medical record for Resident #18 revealed an admission date of 05/30/24 with diagnosis including chronic obstructive pulmonary disease (COPD). Review of the comprehensive admission Minimum Data Set (MDS) assessment, dated 06/06/24, revealed Resident #18 had impaired cognition and did not reject care. Review of a current physician order initiated 08/05/24 revealed Resident #18 was to receive oxygen therapy at two to four liters per minute (LPM) via nasal cannula (NC) every shift. Observation on 09/03/24 at 1:54 P.M. revealed Resident #18 sitting in his wheelchair near the nurse's station. Resident #18's oxygen NC was applied and the oxygen tank gauge needle indicated the tank was empty. 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.
- Potential for harm · D2024-09-05 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard 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 medical record review, family and staff interviews, and review of the facility policy, the facility failed to ensure the medical record reflected a change in condition. This affected one (#20) of 13 residents reviewed for medical record accuracies. The facility census was 46. Findings include: Review of the medical record for Resident #20 revealed a readmission date of 05/30/23 with diagnosis including dementia. Review of the nursing progress notes dated 04/05/24 revealed a note dated 04/05/24 at 6:43 A.M. stating Resident #20 had a reddened area on her right hip and the physician was notified. The progress note dated 04/06/24 at 11:24 P.M. revealed Resident #20 was admitted to the hospital for bradycardia. There was no documentation of Resident #20 having a change in condition on 04/06/24, the physician being notified of the change in condition on 04/06/24, and the physician ordering to send Resident #20 to the emergency room on [DATE]. Review of the hospital records for Resident #20 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.
- Potential for harm · D2024-09-05 · tag F0887 — isolatedEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of immunization records, resident and staff interview, review of policy, and review of the Centers of Disease Control and Prevention (CDC) guidance, the facility failed to offer the residents the COVID-19 vaccination per CDC recommendations. This affected three (#18, #29, and #45) of nine residents reviewed for COVID-19 vaccination. The facility census was 46. Findings include: 1. Review of the medical record for Resident #18 revealed an admission date of 05/30/24 with diagnoses of chronic obstructive pulmonary disease (COPD) and schizophrenia. Review of the Minimum Data Set (MDS) assessment, dated 06/06/24, revealed Resident #18 had impaired cognition. Review of the immunization record, dated 09/05/24, revealed Resident #18 last COVID-19 vaccine was 10/03/22. There was no record of Resident #29 being offered the COVID-19 vaccination since admission. Interview on 09/05/24 at 1:25 P.M. with Infection Preventionist #189 revealed new admission residents receive the vaccine…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-22 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, family and staff interview, and facility policy review the facility failed to notify the family of a residents change of condition and transfer to local hospital for evaluation and treatment of stroke symptoms. This affected one resident (#44) reviewed for notification of change of condition. The facility census was 48. Findings include: Review of the medical record for Resident #44 revealed a re-admission date of 01/23/24 with a diagnosis of cerebral infarct (stroke). Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact. Review of the facility form titled HIPAA/PHI Authorization and Consent Form dated 12/23/23 from admission revealed Resident #44 identified his brother as his emergency contact. Review of the nursing progress noted dated 01/13/24 at 3:23 P.M. for Resident #44 revealed the nurse was called to the resident's room and was noted to have right sided facial droop. Resident #44 complained of feeling right sided numbness…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, staff interview, and review of policy, the facility failed to safely transfer a resident using a mechanical lift device. This directly affected one (#48) of three residents reviewed for assistance with transfers. The facility identified five additional residents (#14, #21, #41, #45, and #49) utilizing a mechanical lift devices. The facility census was 48. Findings include: Review of the medical record of Resident #48 revealed an admission date of 08/10/22. Diagnoses include chronic obstructive pulmonary disease, rheumatoid arthritis, type II diabetes mellitus, venous insufficiency, and neuromuscular dysfunction of bladder. Review of the quarterly minimum data set assessment dated [DATE] revealed Resident #48 was cognitively intact and required extensive assistance for activities of daily living and transfers. Review of the care plan dated 08/19/22 revealed an intervention for falls to include the use of a stand-up lift. A second intervention dated 08/19/22 for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-18 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, review of facility resident list, staff interview and policy review, the facility failed to ensure medications were properly stored when a medication cart was left with a drawer open, the cart unlocked, and unattended. This had the potential to affect two residents (#33 and #34) identified as being independently mobile and confused. The facility census was 48. Findings include: Observation and interview on 12/14/23 at 7:39 A.M., the medication cart was unlocked, the top drawer was open, medications were visible and no staff was in attendance. Licensed Practical Nurse (LPN) #100 exited the room of Resident #37 and verified the cart was unattended and unlocked. Review of a facility identified list revealed two residents (#33 and #34) are independently mobile and have confusion. Review of the policy titled Security of Medication Cart dated 04/12 revealed the medication cart is to be locked when out of view of the nurse.
- Potential for harm · Dcited before2023-12-18 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, review of facility resident list and review of policy, the facility failed to ensure the shared glucometer was disinfected between residents. The facility further failed to ensure the correct disinfecting solution was used to cleanse the glucometer. This had the potential to affect two residents (#36 and #37) identified as using the glucometer. The facility census was 48. Findings include: Observation on 12/14/23 at 7:39 A.M., revealed Licensed Practical Nurse (LPN) #100 was carrying a glucometer when exiting the room of Resident #37. LPN #100 proceeded into the room of Resident #36 with the glucometer and proceeded to perform a fingerstick to obtain a blood glucose reading. LPN #100 had not disinfected the meter between residents. Interview with LPN #100, at the time of the observation verified not having disinfected the glucometer between resident use. Continued observation revealed LPN #100 was using an alcohol prep pad to clean the glucometer; after this surveyor questioned her about not cleaning the meter between residents and thought 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.
Show the remaining 31 citations
- Potential for harm · F2022-06-30 · tag F0868 — widespreadHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — the official record, unedited, may be distressing
Based on staff interview and quarterly quality assessment and assurance (QAA) committee meetings, the facility failed to have a physician attend quarterly QAA committee meetings. This had the potential to affect all 58 residents in the facility. Findings include: Review of the sign-in sheets for the quarterly QAA meetings dated 07/27/21, 12/28/21, 03/29/22, and 06/29/22 revealed the physician was not present during the meetings on 07/27/21 and 12/28/21. Interview on 06/30/22 at 3:52 P.M. with the Administrator confirmed the physician did not attend QAA meetings during the third and fourth quarters of 2021.
- Potential for harm · D2022-06-30 · tag F0567 — failed to protect residents' money held by the home — isolatedHonor the resident's right to manage his or her financial affairs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of personal fund accounts, observation, resident and staff interview, and review of facility policy, the facility failed to ensure residents had access to personal funds. This affected one (#39) out of 26 residents with personal fund accounts. The facility census is 58. Findings include: Review of the personal fund accounts revealed Resident #39 had an account managed by the facility. Review of the most recent quarterly statement revealed as of 06/27/22 Resident #39's remaining balance was $29.95. Observation on 06/27/22 at 12:27 P.M. revealed Resident #39 requested $10 of personal funds from Activities Assistant #429. Activities Assistant #429 asked numerous questions to Resident #39 of why she needed the money and what she planned to purchase. Resident #39 avoided the question for a couple of instances and made a short joking remark. Activities Assistant #429 stated the Business Office Manager was out that day and Resident #38 could not obtain her funds until tomorrow. Medical Records Clerk #432 offered to loan Resident #39 $10 until the next day. 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.
- Potential for harm · D2022-06-30 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to provide privacy when clipping a resident's toe nails for one (#313) resident randomly observed. The facility census was 58. Findings include: Review of the medical record revealed Resident #313 was admitted on [DATE]. Diagnosis included Alzheimer's disease, major depressive disorder, and dementia. Observation on 06/28/22 at 10:55 A.M. revealed Licensed Practical Nurse (LPN) #455 clipping Resident #313's toe nails in the resident common area. Residents also present in the common area included Resident #8, #22, #34, #35, #40, #56, and #59. Interview on 06/28/22 at 11:11 A.M. with Licensed Practical Nurse (LPN) #455 verified clipping Resident #313's toe nails in the common area. Review of facility policy titled Quality of Life, created on 11/13/17, revealed the resident shall be cared for in a manner that is respectful and dignified in recognition of their individuality.
- Potential for harm · Dcited before2022-06-30 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, resident interview, staff interview and review of the facility policy, the facility failed report to the State Survey Agency an allegation when a resident intentionally poured water onto a confused resident. This affected two (#39 and #54) out of 45 residents reviewed for abuse. The current census is 58. Findings include: Review of Resident #39's medical record revealed an admission dated of 07/11/19. Diagnoses included borderline personality disorder, type two diabetes mellitus, major depressive disorder, peripheral vascular disease, osteoarthritis, hyperlipidemia, insomnia, epilepsy, and hypertension. Review of the Minimum Data Set (MDS) assessment, dated 05/09/22, revealed the resident was cognitively intact. Review of Resident #39's progress notes revealed the record was silent of any resident to resident interactions. Interview on 06/27/22 at 9:24 A.M., Resident #39 stated Resident #54 had wandered into her room, but she had not come back since dumping a cup of water on her. Resident #39 stated about two to three weeks ago Resident #54 came into her room…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-06-30 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, resident interview, staff interview and review of the facility policy, the facility failed investigate an allegation when a resident intentionally poured water onto a confused resident. This affected two (#39 and #54) out of 45 residents reviewed for abuse. The current census is 58. Findings include: Review of Resident #39's medical record revealed an admission dated of 07/11/19. Diagnoses included borderline personality disorder, type two diabetes mellitus, major depressive disorder, peripheral vascular disease, osteoarthritis, hyperlipidemia, insomnia, epilepsy, and hypertension. Review of the Minimum Data Set (MDS) assessment, dated 05/09/22, revealed the resident was cognitively intact. Review of Resident #39's progress notes revealed the record was silent of any resident to resident interactions. Interview on 06/27/22 at 9:24 A.M., Resident #39 stated Resident #54 had wandered into her room, but she had not come back since dumping a cup of water on her. Resident #39 stated about two to three weeks ago Resident #54 came into her room and Resident #39 had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-06-30 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility policy, and staff interview the facility failed to complete a baseline care plan with oxygen included as a focus for three residents, (#264, #34, and #213) out of five residents reviewed for baseline care plans. The current census is 58. Findings include: 1. Record review of Resident #264 revealed the resident had been admitted to the facility on [DATE]. Diagnoses for Resident #264 include dementia with behaviors, diabetes, falls, neuralgia, and cognitive deficit. Review of Resident #264's Minimum Data Set (MDS) assessment, dated 06/18/22, revealed the resident had impaired cognition and received supplemental oxygen. Review of the physician orders dated 06/14/22 revealed the resident was to receive oxygen to maintain oxygen level above 90 percent. Review of Resident #264's baseline care plans, dated 06/14/22, revealed no care plan for for oxygen. Per the care plans dated 06/26/22 the resident had a goal added to the 'basic needs' focus with the intervention of oxygen as…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-06-30 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to complete comprehensive care plans for one (#34) out of 24 residents reviewed for care plans. The current census was 58. Findings include: Review of the medical record revealed Resident #34 was admitted on [DATE]. Diagnosis included protein-calorie malnutrition, acute respiratory failure with hypoxia, weakness, cognitive communication deficit, osteoarthritis, hypertension, and Alzheimer's disease. Review of Resident #34's comprehensive care plan revealed it wasn't completed until 02/25/22. Interview on 06/30/22 at approximately 12:30 P.M. with Registered Nurse Regional Nurse #456 verified Resident #34 was admitted on [DATE] and a comprehensive care plan was not initiated until 02/25/22.
- Potential for harm · Dcited before2022-06-30 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident interview, family interview, review of the facility policy, and staff interview, the facility failed to conduct care conferences with residents and their families. This affected two (#6 and #39) out of three residents reviewed for care conferences. The facility failed to revise a care plan following the assessment of one (#34) out of 24 residents reviewed for care plans. The current census was 58. Findings include: 1. Review of the medical record of Resident #6 revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic bronchitis, dementia with behaviors, heart disease, weakness, history of fractures, and depression. Review of Resident #6's Minimum Data Set (MDS) assessment, dated 06/03/22, revealed the resident had impaired cognition and behavior, and was a two person assistance with Activities of Daily Living, (ADL). Further review of Resident #6's medical records revealed there was no documentation of care conferences being conducted from 06/2021…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-06-30 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on resident interview, staff interview and record review, the facility failed to obtain orders for the flushing of a gastrostomy tube (g-tube) upon admission to the facility, failed to provide flushes as ordered by the physician, and failed to have a policy regarding g-tube care and treatment . This affected one (#213) of one resident reviewed for a g-tube. The facility census was 58. Findings include: Review of the medical record for Resident #213 revealed an admission date of 06/22/22 with diagnoses of chronic obstructive pulmonary disease, tracheostomy status, gastrostomy status, and dysphagia. Review of physician orders upon admission revealed an order for an oral diet. There were no orders upon admission for g-tube flushes. Review of a physician order dated 06/24/22 revealed Resident #213's g-tube should be flushed with 60 milliliters (mL) of water every eight hours to maintain patency. Review of the treatment administration record (TAR) for Resident #213 revealed g-tube flushes were not given on 06/24/22 at 10:00 P.M., on 06/25/22 at 6:00 A.M., 2:00 P.M., and 10:00 P.M.,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-06-30 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, observation, and staff interview, the facility failed to provide oxygen per physician order for one (#40) out of two residents reviewed for oxygen therapy. The current census was 58. Findings include: Review of the medical record for Resident #40 revealed an admission date of 04/09/20 with medical diagnoses of dementia, paranoid personality disorder, and insomnia. Review of the quarterly Minimum Data Set assessment, dated 05/09/22, revealed Resident #40 had severely impaired cognition, required extensive assistance of one person for bed mobility and transfers, and limited assistance of one person for toilet use and hygiene. Review of a physician order dated 10/21/21 revealed Resident #40 received oxygen therapy at 2 liters per minute (L/min) per nasal cannula every shift as needed for dyspnea and respiratory distress. Review of the medication administration record (MAR) for Resident #40 dated 06/27/22 through 06/29/22 revealed no documentation of the resident having any dyspnea or respiratory distress and no documentation oxygen was administered.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2019-07-25 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, and review of facility policies, the facility failed to ensure the ice machine was maintained in a sanitary manner. This had the potential to affect all residents except two (Residents #10 and #56) who the facility identified as not receiving any food by mouth (NPO). The facility census was 72. Findings include: Observation of the facility kitchen on 07/22/19 at 9:13 A.M., revealed the bin type ice machine contained a layer of black colored debris, which appeared to be mold, across the inside top of the ice machine. The interior sides of the ice machine contained a grayish-white lime-like substance. Interview and observation with Dietary Manager #220 at the time of the above observation verified these findings. She stated the maintenance department was responsible for sanitizing the ice machine. She was unable to state when the ice machine had been cleaned last. She stated it should be cleaned twice weekly. Further interview with Dietary Manager #220 on 07/24/19 at 11:54 A.M., verified the facility had no documentation indicating the ice…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2019-07-25 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 review of the facility's Legionella and waterborne illness prevention documentation and staff interview, the facility failed to implement a legionella control plan with identified control measures and documentation. This had the ability to affect 72 of 72 residents residing in the facility. The census was 72. Findings include: Review of a facility policy titled Legionella dated [DATE] revealed the facility would proactively maintain water systems within the facility against the bacterium Legionella and other water-borne pathogens. The facility would specify protocols and acceptable ranges for control measures and document the results of testing and corrective actions taken when control limits are not maintained. Further review of the facility Legionella risk management documentation revealed no flow sheet indicating potential risk areas in the facility. The facility indicated their water temperatures were normally above or below the temperature Legionella grows best (77 to 108 degrees) and stated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-07-25 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and review of the facility's policy, the facility failed to implement the facility policy for investigating and reporting an injury of unknown origin. This affected one (#56) of one resident reviewed for injury of unknown origin. The census was 72. Findings include: Review of the medical record for Resident #56 revealed an admission date of 04/11/18. Diagnoses included hemiplegia, hemiparesis, dementia and anxiety. Review of the physician's orders revealed an order dated 02/14/19 to perform weekly skin checks with showers. Review of the Minimum Data Set assessment dated [DATE] revealed Resident #56 was assessed as being cognitively moderately impaired and for skin issues had moisture associated skin damage. The resident also is a tube feed and does not receive any food by mouth. Review of the plan of care dated 03/22/19 for Resident #56 revealed a plan for being at risk for impaired skin integrity due to cerebrovascular accident with hemiplegia. The intervention…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-07-25 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and review of the facility's policy, the facility failed to report an injury of unknown injury to the state agency. This affected one (#56) of one resident reviewed for injury of unknown origin. The census was 72. Findings include: Review of the medical record for Resident #56 revealed an admission date of 04/11/18. Diagnoses included hemiplegia, hemiparesis, dementia and anxiety. Review of the physician's orders revealed an order dated 02/14/19 to perform weekly skin checks with showers. Review of the Minimum Data Set assessment dated [DATE] revealed Resident #56 was assessed as being cognitively moderately impaired and for skin issues had moisture associated skin damage. The resident also is a tube feed and does not receive any food by mouth. Review of the plan of care dated 03/22/19 for Resident #56 revealed a plan for being at risk for impaired skin integrity due to cerebrovascular accident with hemiplegia. The intervention included to monitor skin during baths…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-07-25 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and review of the facility's policy, the facility failed investigate an injury of unknown origin. This affected one (#56) of one resident reviewed for injury of unknown origin. The census was 72. Findings include: Review of the medical record for Resident #56 revealed an admission date of 04/11/18. Diagnoses included hemiplegia, hemiparesis, dementia and anxiety. Review of the physician's orders revealed an order dated 02/14/19 to perform weekly skin checks with showers. Review of the Minimum Data Set assessment dated [DATE] revealed Resident #56 was assessed as being cognitively moderately impaired and for skin issues had moisture associated skin damage. The resident also is a tube feed and does not receive any food by mouth. Review of the plan of care dated 03/22/19 for Resident #56 revealed a plan for being at risk for impaired skin integrity due to cerebrovascular accident with hemiplegia. The intervention included to monitor skin during baths and weekly.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-07-25 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to notify the ombudsman when residents were transferred or discharged from the facility. This affected two (#67 and #51) of four reviewed for hospitalization and discharge. The facility identified 64 residents who were transferred or discharged from the facility since 04/01/19. The census was 72. Findings include: 1. Review of the medical record for Resident #67 revealed an admission date of 07/03/14. Diagnoses include Dementia, Parkinson's disease and Schizophrenic. Review of the Lutheran Homes Society -[NAME] Campus, Bed Hold and leave notices dated 07/24/14 for Resident #67 representative which acknowledged they did not want a bed hold, this is the only paper which has been signed. Review of the nurse notes on 06/07/19 at 4:00 P.M. revealed Resident #67 was sent out to the hospital for evaluation per doctor for acute onset of weakness, tachycardia and unresponsiveness. Interview with Social Services #250 on 07/25/19 at 1:02 P.M. verified…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-07-25 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and review of the facility policy, the facility failed to ensure bed hold notice was given to the resident or representative of transfer to the hospital. This affected one (#67) of four residents reviewed for hospitalization and discharge. The facility identified 64 residents who were transferred or discharged from the facility since 04/01/19. The census was 72. Findings include: Review of the medical record for Resident #67 revealed an admission date of 07/03/14. Diagnoses include Dementia, Parkinson's disease and Schizophrenic. Review of the Lutheran Homes Society -[NAME] Campus , Bed Hold and Leave notices upon admission dated 07/24/14 for Resident #57 was signed by the representative which acknowledged they did not want a bed hold and this is the only paper which has been signed. Review of the nurse notes on 06/07/19 at 4:00 P.M., revealed Resident #67 was sent out to the hospital for evaluation per doctor for acute onset of weakness, tachycardia and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-07-25 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to update a care plan when a pressure reducing intervention was discontinued. This affected one (#37) of three residents reviewed for pressure ulcers. The facility identified two residents with pressure ulcers. The census was 72. Findings include: Review of Resident #37's medical record revealed an admission of 03/30/19. Diagnoses included dysphagia, unspecified visual loss, umbilical hernia, essential hypertension, hyperlipidemia, and chronic bronchitis. Review of the most recently completed Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 was severely cognitively impaired and was assessed with one unstageable (a localized area of tissue necrosis and can be covered by slough or eschar) pressure ulcer that was present on admission or re-entry to the facility. Review of a skin integrity care plan dated 03/30/19 revealed an intervention for Resident #37 to have pressure relieving boots on at all times except during…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-07-25 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure the monitoring of blisters and bug bites on resident was monitored per physician's order. This affected one (#56) of one reviewed for skin conditions. The census was 72. Findings include: Review of the medical record for Resident #56 revealed an admission date of 04/11/18. Diagnoses included hemiplegia, hemiparesis, dementia and anxiety. Review of the physician's orders revealed an order dated 02/14/19 to perform weekly skin checks with showers. Review of the Minimum Data Set assessment dated [DATE] revealed Resident #56 was assessed as being cognitively moderately impaired and for skin issues had moisture associated skin damage. The resident also is a tube feed and does not receive any food by mouth. Review of the plan of care dated 03/22/19 for Resident #56 revealed a plan for being at risk for impaired skin integrity due to cerebrovascular accident with hemiplegia. The intervention included to monitor skin during baths and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-07-25 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, facilty policy review and staff interview, the facility failed to implement a pressure reducing device to prevent pressure ulcers for a resident with a history of pressure sores. This affected one (#37) of three residents reviewed for pressure ulcers. The facility identified two residents with pressure ulcers. The census was 72. Findings include: Review of Resident #37's medical record revealed an admission of 03/30/19. Diagnoses included dysphagia, unspecified visual loss, umbilical hernia, essential hypertension, hyperlipidemia, and chronic bronchitis. Review of the most recently completed Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 was severely cognitively impaired, required extensive assistance with bed mobility, and was assessed with one unstageable (a localized area of tissue necrosis and can be covered by slough or eschar) pressure ulcer that was present on admission or re-entry to the facility. Review of a physician order 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.
- Potential for harm · Dcited before2019-07-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, and medical record review, the facility to ensure fall interventions were in place as ordered and care planned. This affected one (#51) of two residents reviewed for falls. The facility identified six residents with orders for pressure pad alarms as fall interventions. The census was 72. Findings include: Review of Resident #51's medical record revealed an admission date of 05/10/19. Diagnoses included acute kidney failure, chronic kidney disease, heart failure, diabetes mellitus type II, chronic obstructive pulmonary disease, and major depression. Review of the most recently completed Minimum Data Set (MDS) assessment completed 06/09/19 revealed Resident #51 was severely cognitively impaired and was assessed as requiring limited assistance with bed mobility, transfers, and walking in the room and corridor. Review of a physician order dated 07/05/19 revealed Resident #51 was ordered a pressure pad alarm to the recliner and staff was to check placement and function every shift. Review of a fall care plan dated 07/05/19 revealed Resident #51 had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-07-25 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, and medical record review, the facility to ensure a urinary catheter was maintained in a manner to prevent contamination. This affected one (#51) of one residents reviewed for urinary catheters. The facility identified four residents with urinary catheters. The census was 72. Findings include: Review of Resident #51's medical record revealed an admission date of 05/10/19. Diagnoses included acute kidney failure, chronic kidney disease, heart failure, diabetes mellitus type II, chronic obstructive pulmonary disease, and major depression. Review of Resident #51's July 2019 medication orders revealed he was not currently prescribed an antibiotic, and review of nursing progress notes between 07/05/19 and 07/24/19 revealed Resident #51 had no recent urinary tract infections. Observation on 07/23/19 at 3:42 P.M., revealed Resident #51 sitting in his reclining chair with his eyes closed. Further observation revealed Resident #51's urinary catheter collection bad was laying flat on the floor in direct contact with the tile floor and was noted to have a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-07-25 · tag F0727 — failed to provide required RN coverage — isolatedHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — the official record, unedited, may be distressing
Based on review of facility staffing tools, nursing schedules, and and staff interview, the facility failed to ensure a registered nurse (RN) was on duty at least eight consecutive hours a day, seven days a week. This affected 72 of 72 residents residing in the facility. Findings include: Review of facility staffing tool documents dated 07/19/19, 07/20/19, and 07/21/19, revealed the facility did not have a RN on duty during the on the 7:00 A.M. to 7:30 P.M. shift or the 7:00 P.M. to 7:30 A.M. shift. Review of nurse staffing schedules provided by the facility dated 07/19/19, 07/20/19, and 07/21/19 revealed the facility did not have an RN on duty on any shift during the three days. Interview on 07/25/19 at approximately 12:30 P.M., with Director of Nursing (DON) #1 verified the facility did not have an RN on duty on any shift on 07/19/19, 07/20/19, and 07/21/19.
- Potential for harm · Dcited before2019-07-25 · tag F0730 — isolatedObserve each nurse aide's job performance and give regular training.
What the surveyor found here — the official record, unedited, may be distressing
Based on employee personnel file review, staff interview, and review of facility policy, the facility failed to ensure state tested nurse aides (STNA) were provided with at least 12 hours of annual in-service training. This affected two (#500 and #501) nurse aide employee files reviewed. This deficient practice had the potential to affect 72 of 72 residing in the facility. The census was 72. Findings include: 1. Review of STNA #500's personnel file revealed a hire date of 05/19/16. Further review of the employee file revealed STNA #500 had not had 12 hours of in-servicing in the last year. 2. Review of STNA #501's personnel file revealed a hire date of 03/16/17. Further review of the employee file revealed STNA #501 had not had 12 hours of in-servicing in the last year. Interview on 07/25/19 at 3:31 P.M. with Director of Human Resources #502 verified STNA #500 and STNA #501 did not have 12 hours of annual in-service training.
- Potential for harm · D2019-07-25 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, medical record review, and review of a facility policy, the facility failed to ensure correct doses of medications were available for residents, and failed to administer medications per physician orders. This affected one (#44) of five residents reviewed for unnecessary medications. The facility identified 40 residents who received antidepressant medications in the facility. The census was 72. Findings include: Review of Resident #44's medical record revealed an admission date of 10/11/16. Diagnoses included unspecified dementia without behavioral disturbances, unspecified psychosis, chronic kidney disease, major depression, anxiety, and diabetes mellitus type II. Review of the most recently completed Minimum Data Set (MDS) assessment dated [DATE] MDS revealed Resident #44 had short term and long term memory problems, and severely impaired cognitive skills for daily decision making. Resident #44 was assessed with no behaviors in the look-back period of the assessment.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-07-25 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of a facility policy, the facility failed to ensure monthly pharmacy review irregularities were reviewed by the physician. This affected one (#25) of five residents reviewed for unnecessary medications. The facility census was 72. Findings include: Review of Resident #25's medical record revealed an admission date of 06/30/17. Medical diagnoses included Parkinson's disease, dementia with behaviors, hypertension, anxiety disorder, major depressive disorder, syncope and collapse, dysphagia, and generalized weakness. Review of the resident's Minimum Data Set assessment dated [DATE] revealed no impairment in cognition. The resident received antipsychotic, antianxiety, antidepressant, and opioid medication. Review of the resident's monthly pharmacy reviews revealed recommendations were made to the physician in July 2018, December 2018, January 2019, and February 2019. Further review of the resident's medical record revealed no indication what the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-07-25 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of a facility policy, the facility failed to ensure a resident's as needed (PRN) antianxiety medication was time limited. This affected one (#25) of five residents reviewed for unnecessary medications. The facility identified 14 residents on antianxiety medications. The facility census was 72. Findings include: Review of Resident #25's medical record revealed an admission date of 06/30/17. Medical diagnoses included Parkinson's disease, dementia with behaviors, hypertension, anxiety disorder, major depressive disorder, syncope and collapse, dysphagia, and generalized weakness. Review of the resident's Minimum Data Set assessment dated [DATE] revealed no impairment in cognition. The resident received antianxiety medication. Review of the resident's physician's orders revealed an order dated 11/13/18 for Ativan (antianxiety medication) 0.5 milligrams (mg) twice daily as needed (PRN) for anxiety. Review of the resident's Medication Administration Record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · Ccited before2024-09-05 · tag F0730 — widespreadObserve each nurse aide's job performance and give regular training.
What the surveyor found here — the official record, unedited, may be distressing
Based on personnel file review and staff interview, the facility failed to ensure one of four State Tested Nursing Assistants (STNA) received an annual performance review. This had the potential to affect all 46 residents residing in the facility. Findings include: Review of the personnel file of STNA #195 revealed a hire date of 05/19/23. The file was absent of any yearly performance review having been completed. Interview on 09/05/24 at 11:00 A.M. with Human Resources #202 verified there was no yearly performance review completed for STNA #195.
- No harm found · Ccited before2022-06-30 · tag F0730 — widespreadObserve each nurse aide's job performance and give regular training.
What the surveyor found here — the official record, unedited, may be distressing
Based on staff interview and review of personnel files, the facility failed to ensure State Tested Nurse Aides (STNA) received annual in-services. This affected two (STNA #401 and STNA #414) our of 18 STNAs employeed and had the potential to affect all 58 residents residing in the facility. Findings include: Review of the personnel files for STNA #401 revealed a hire date of 06/24/13. There was no evidence of the completion of 12 hours of in-services every 12 months. Review of the personnel files for STNA #414 revealed a hire date of 04/21/04. There was no evidence of the completion of 12 hours of in-services every 12 months. Interview on 06/30/22 at 1:30 P.M. with the Director of Human Resources confirmed the STNAs had not completed 12 hours of in-services over the last 12 months.
- No harm found · B2022-06-30 · tag F0640 — patternEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record review and staff interview, the facility failed to transmit Minimum Data Set, (MDS) assessments for three (#266, #267, and #2) out of 24 residents reviewed for MDS assessments. The current census was 58. Findings include: 1. Review of the medical record for Resident #266 revealed the resident was admitted to the facility on [DATE]. Diagnoses include hip replacement, cancer, hypertension, and pressure ulcers. The resident was discharged from the facility in 03/2022. Review of the MDS assessments revealed there was no discharged assessment transmitted in 03/2022 for Resident #266. 2. Record review for Resident #267 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #267 include heart disease, renal failure, and thyroid disease. The resident was discharged from the facility in 03/2022. Review of the MDS assessments revealed there was no discharged assessment transmitted in 03/2022 for Resident #267. 2. Record review for Resident #2 revealed 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.
- No harm found · C2019-07-25 · tag F0838 — failed to assess facility resources and resident needs — widespreadConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
What the surveyor found here — the official record, unedited, may be distressing
Based on facility assessment review and staff interview, the facility failed to include an evaluation of the overall number of facility staff needed to ensure sufficient number of qualified staff are available to meet the residents' needs. This deficient practice had potential to affect 72 of 72 residents residing in the facility. The census was 72. Findings include: Review of the facility assessment from 2019 revealed no documentation of the facility evaluating the staff needed to ensure sufficient number of qualified staff are available to meet each resident's need. The assessment failed to include the knowledge and skills required of staff to maintain the highest resident well-being and current professional standards of practice based on a competency-based approach, and did not address individual staff assignments and systems for coordination and continuity of care. Interview on 07/25/19 at 2:34 P.M. with Administrator #2 verified the facility assessment did not include an evaluation of facility staffing needs and staffing knowledge and skills.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| DUMKE, JAMES | Individual | W-2 MANAGING EMPLOYEE | since 09/24/2001 |
| MARSHALL, WILLIAM | Individual | W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 02/01/2015 |
| SCHALK, LORINDA | Individual | W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR; CORPORATE OFFICER | since 01/01/2014 |
| SCHULTE, JEFFERY | Individual | W-2 MANAGING EMPLOYEE | since 09/16/2007 |
| BAUERLE, STEPHEN | Individual | CORPORATE DIRECTOR | since 04/16/2023 |
| BOWE, STEPHEN | Individual | CORPORATE DIRECTOR | since 04/16/2023 |
| DEMPSEY, JEFFREY | Individual | CORPORATE DIRECTOR | since 04/16/2023 |
| MARSHALL, ANITA | Individual | CORPORATE DIRECTOR | since 04/07/2022 |
| RAHE, KEVIN | Individual | CORPORATE DIRECTOR | since 07/01/2021 |
| SIEBEN, PAUL | Individual | CORPORATE DIRECTOR | since 07/01/2021 |
| SYNDER, MARK | Individual | CORPORATE DIRECTOR | since 07/01/2021 |
| WARNER, MELISSA | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 04/07/2022 |
| WUNSCHEL, LEE | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 01/01/2017 |
| AMONETTE, CASEY | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 12/01/2021 |
| BARROR, JEFFERY | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 09/14/2021 |
| COCKE, AMBER | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 12/07/2021 |
| SUBER, LADINA | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 12/15/2021 |
CMS files one row per role, so the 24 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $856K paid to related parties — landlords or management companies under common ownership — equal to about 12% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OH
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Ohio Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 366162. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-09-05, 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.