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Amberwood Manor

245 South Broadway, New Philadelphia, OH 44663 · For profit - Limited Liability company · 48 certified beds · (330) 339-2151 Medicare & Medicaid certified

Call the home — (330) 339-2151 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0602) — cited Dec 2024Resident-funds citation (F0567)Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0602), cited Dec 2024
  • it has a citation for mishandling residents’ money or property (F0567)
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its payroll-based staffing rating is low (1/5)
  • about 24% of its spending goes to commonly-owned related companies

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 5 of 5

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

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
163 W High Ave · (330) 556-4226 · Call to confirm hours
Pharmacy
315 E High Ave · (330) 364-5519 · Call to confirm hours
Grocery
220 1st Dr SW · (330) 437-9633 · Call to confirm hours
Park
100 E High Ave · (330) 339-3636 · Typically dawn to dusk
Place of worship
147 S Broadway St · (330) 440-6777

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

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 4 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased5.1%5.3%15.4%typical for the state — see note marked double-dagger below the table
Long-stay residents who lose too much weight8.2%6.2%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.2%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.4%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms30.5%30.1%6.5%typical for the state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury3.4%3.2%3.3%typical
Long-stay residents whose ability to walk worsened7.2%6.1%16.1%worse than state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication30.6%25.5%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%94.5%95.3%typical
Long-stay residents with pressure ulcers7.1%3.4%4.7%worse
Long-stay residents with worsening bladder/bowel control17.4%21.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table10.9%8.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine67.1%75.6%79.4%worse

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.

0.25U.S. median 0.31
Therapy hours / resident / day
0.15hours / resident / day
Physical therapy
0.08hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.25 therapist hours per resident per day in 2026Q1 — more than 34% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 14% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified95.7%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened4.3%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFsnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

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

Staffing

RN hours/ resident / day
LPN hours/ resident / day
Aide hours/ resident / day
Total nurse hours/ resident / day
RN hoursweekends
44.8%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 48 beds and averages 36.1 residents a day — about 75% occupied, or roughly 12 beds typically open. It usually has some room. 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.

Weekend coverage: total nurse staffing is 3.00 hrs/resident/day on weekends vs 3.56 on weekdays — 16% thinner on weekends. RN hours go from 1.03 to 0.64 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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

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

Inspection trend

10
deficiencies at the latest standard inspection (2025-01-23)
6
at the previous standard inspection (2023-01-19)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.

  • Potential for harm · E2025-01-23 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to maintain air temperatures at a comfortable level and failed to ensure floors and bathtubs were cleaned on the South unit. This affected all 22 residents (#2, #3, #5, #8, #9, #10, #11, #13, #15, #16, #17, #19, #20, #22, #24, #26, #28, #29, #31, #32, #238, and #240) who resided on the South unit. Findings Included: 1. Review of an email dated 07/31/24 at 2:35 P.M. revealed the Heating and Cooling company emailed the Administrator indicating the packaged terminal air conditioner (P-TAC ) units needed to be replaced in the facility due to the fact that they were [AGE] years old and could not be repaired anymore. Review of an email dated 09/11/24 at 4:18 P.M. revealed the Administrator emailed the Heating and Cooling company to ask if once the electricity was completed they would have to switch over right away with the new P-TAC units or could they do the electricity and then wait to install the P-TAC units. Review of an email dated 09/16/24 at…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-23 · tag F0567 — failed to protect residents' money held by the home — isolated
    Honor 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of personal funds records and interview, the facility failed to obtain appropriate witness signatures on the authorization for handling funds. This affected one (Resident #8) of five residents whose funds were reviewed. Findings include: During an interview on 01/21/25 at 4:11 P.M., Resident #8's granddaughter stated Resident #8 was a Medicaid recipient. The family received no resources for Resident #8 and had never been asked to sign a paper authorizing the facility to handle funds. To the best of the granddaughter's knowledge, Resident #8 did not have a personal funds account with the facility. Review of a list of resident funds handled by the facility revealed Resident #8 did have a personal funds account managed by the facility. Review of the authorization and agreement to handle resident funds indicated recurring social security benefit payments were to be direct deposited into the account with automatic transfer of care cost payments to the facility with Resident #8…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-23 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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 record review and interviews, the facility failed to administer medications as ordered to Resident #5 and Resident #238. This affected two (Resident #5 and #238) out of six residents reviewed for medications. Facility census was 37. Findings include: 1. Review of the medical record revealed Resident #238 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included type 2 diabetes, severe morbid obesity, history of transient ischemic attack, and major depressive disorder. The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #238 was cognitively intact. Review of physician orders revealed Resident #238 was ordered Lantus (insulin) 15 units at 6:00 A.M. and Lantus 50 units at 7:00 P.M. to 11:00 P.M. Resident #238 had an order from 06/25/24 for metformin (antidiabetic agent) 750 milligrams twice a day. No special instructions or parameters were in place for metformin or Lantus to be held. Review of the medication administration record (MAR) dated 01/12/25 for the 7:00 P.M. to…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-23 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record and interview the facility failed to ensure weekly wound assessments were completed for Resident #5. This affected one resident (Resident #5) of three reviewed for pressure ulcers. Findings included: Review of the medical record revealed Resident #5 was admitted to the facility on [DATE]. Diagnoses included chronic kidney disease, respiratory failure, diabetes, anemia, atrial fibrillation, obstructive sleep apnea, stage 4 pressure ulcer, hypertension and accidental discharge of firearms. Review of the plan of care dated 04/03/24 and edited 01/01/25 revealed Resident #5 had a wound to the left posterior thigh. Interventions included the in-house skin/wound team would see and treat him weekly and as needed. Review of the physician's order dated 10/23/24 revealed Resident #5 was ordered one gram of gentamicin cream 0.1 percent twice a day to the left posterior thigh, cleanse with normal saline, apply the gentamicin cream to the wound bed cover with an abdominal dressing and do…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure fall interventions were in place and appropriate for Resident #14. The facility also failed to ensure Resident #26's wheelchair was not locked when Resident #26 was left unattended. This affected two (Resident #14 and #26) out of five residents reviewed for accidents. The facility census was 37. Findings include: 1. Review of the medical record revealed Resident #14 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included Alzheimer's disease, major depressive disorder, anxiety, manic episode, epilepsy, acute kidney failure, fibromyalgia, and irritable bowel syndrome. A progress note dated 11/22/24 at 8:45 P.M. revealed Resident #14 was found on the bathroom floor in front of the toilet. Care plan for falls revealed an intervention dated 11/26/24 revealed a motion sensor to be placed in the bathroom. A progress note dated 11/29/24 at 12:24 P.M. revealed Resident #14 was found in the bathroom. Review of the fall documentation…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-23 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview and facility policy the facility failed to ensure Resident #137 was provided fluids to maintain hydration. This affected one resident (Resident #137) of one residents reviewed for hydration. Findings include: Review of Resident #137's medical record revealed the resident was re-admitted on [DATE] with diagnoses including congestive heart failure, respiratory failure with hypoxia, type 2 diabetes mellitus, protein-calorie malnutrition, diabetic retinopathy without macular edema, chronic kidney disease stage 4 (severe), non-rheumatic mitral (valve) insufficiency, myocardial infarction, cognitive communication deficit, anxiety, and hypokalemia, Resident #137's nutritional assessment dated [DATE] indicated Resident #137's calculated fluid need was between 1900 milliliters (ml) to 2100 ml per day. Review of Resident #137's fluid intake documentation dated 01/12/25 to 01/21/25 indicated Resident #137's daily intake of fluid was between 480 ml and 960 ml 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-23 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview and policy review, the facility failed to ensure monthly drug regimen reviews identified irregularities in a resident's drug regimen and failed to ensure pharmacy recommendations were responded to in a timely manner. This affected two (Residents #17 and #26) of five residents reviewed for medication use. Findings include: 1. Review of Resident #17's medical record revealed diagnoses including Alzheimer's disease, malignant neoplasm of the esophagus, and chronic pain syndrome. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #17 had short and long term memory problems and severely impaired cognitive skills for daily decison making. a. Review of a monthly pharmacy review dated 06/03/24 indicated Resident #17 had orders for both acetaminophen 650 milligrams (mg) every 12 hours as necessary and hydrocodone/acetaminophen (narcotic pain medication) 5/325 mg every six hours as needed for pain. The pharmacy requested clarification of the parameters…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-23 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement 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 record review, pharmacy recommendations, and interview, the facility failed to ensure as needed psychotropic drugs were limited to 14 days without a rationale for the order to be extended. This affected one (Resident #26) out of five residents reviewed for unnecessary medications. Facility census was 37. Findings include: Review of the medical record revealed Resident #26 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included hepatic encephalopathy, traumatic brain injury, major depressive disorder, anxiety disorder, vascular dementia, visual hallucinations, and violent behavior. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #26 had moderately impaired cognition. The MDS also revealed Resident #26 received antianxiety and antidepressant medications. The pharmacy recommendation dated 09/06/24 revealed Resident #26 was ordered Ativan (psychotropic/antianxiety) one milligram twice a day as needed. The pharmacy recommendation revealed as needed psychotropic…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-23 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based of observations, review of the medical record and interview the facility failed to ensure medications were not left at bedside for Resident #15. This affected one resident ( Resident #15) of five residents reviewed for accidents. Findings included: Review of the medical records revealed Resident #15 was admitted to the facility on [DATE]. Diagnoses included diabetes, hypercholesterolemia, hyperkalemia, acute respiratory failure, hypertension , glaucoma, atrial fibrillation, heart failure, kidney disease, dementia, generalized anxiety disorder, retention of urine, and abnormal weight loss. Review of the January 2025 physician's orders revealed Resident #15 had an order for fluticasone propionate nasal spray 50 micrograms one spray each nostril daily. He did not have an order to leave medications at bedside or he could administer himself. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #15 had intact cognition. Observation on 01/21/25 at 8:50 A.M. revealed Resident #15 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-23 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview and policy review the facility failed to ensure staff performed hand hygiene to prevent possible cross contamination during Resident #7's medication administration. This affected one resident (Resident #7) of five observed for medication administration. The facility census was 37. Findings include: Resident #7 was admitted to the facility on [DATE] with diagnoses including focal traumatic brain injury, contracture, hypertension (high blood pressure), mild intellectual disabilities, hearing loss, dysphagia, oral phase , pain, dysphagia, and oropharyngeal phase. An observation on 01/22/25 at 8:32 A.M. of Registered Nurse (RN) #364 administer medications to Resident #7 revealed RN #364 failed to perform hand hygiene prior to obtaining Resident #7's medications and dispensing the medications in a medication cup. RN #364 obtained a medication cup by placing her index finger inside the medication cup. RN #364 then proceeded to walk to the nursing station and opened 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 15 citations
  • Potential for harm · Ecited before2024-12-20 · tag F0602 — failed to protect residents from theft of their belongings — pattern
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, facility investigation, self-reported incident (SRI) review, policy and procedure for Abuse, Neglect and Exploitation and, policy and procedure for Inventory Control of Controlled Substances review, the facility failed to ensure controlled medication was not misappropriated. This affected six (Residents #1, #2, #3, #4, #5, and #6) out of 41 residents that resided in the facility at the time of misappropriation. Findings include: Review of SRI tracking number 254526 dated 11/27/24, medical records, and facility investigation revealed controlled medications for Residents #1, #2, #3, #4, #5, and #6 had been misappropriated by Registered Nurse (RN) #103. The morning of 11/27/24, Licensed Practical Nurse (LPN) #101 completed the narcotic count with an agency RN #103. The count was correct. LPN #101 was administering medication and noticed some…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · Dcited before2023-08-03 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of a facility self-reported incident (SRI), facility investigation, employee personnel file, facility policy review, and interview, the facility failed to ensure a resident was free from misappropriation of medications. This affected one resident (#8) of three residents reviewed for misappropriation. Findings include: Review of the medical record for the Resident #8 revealed an admission date of 05/29/18. Diagnoses included chronic kidney disease, chronic pain, chronic ulcer of the lower leg, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/23/23, revealed Resident #8 had intact cognition. The resident required extensive assistance from two staff for bed mobility and extensive assistance from one staff for dressing and personal hygiene. Review of Resident #8's physician order, dated 05/02/23, revealed the order for oxycodone HCL oral tablet, give 10 milligrams (mg) every six hours, 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · Dcited before2023-08-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, interview, and policy review, the facility failed to ensure proper physical assistance was provided to prevent a fall. This affected one resident (#11) of three residents reviewed for falls. Findings include: Review of the Resident #11's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, flaccid hemiplegia affecting right dominant side, aphasia following cerebral infarction, morbid obesity, and repeated falls. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 02/11/23, revealed the resident's Brief Interview for Mental Status (BIMS) score could not be assessed due to the resident rarely/never being understood. The resident required extensive, two-person physical assistance for bed mobility, transfers, dressing, and personal hygiene; and was totally dependent…

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

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · D2023-08-03 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide 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

    Based on observation, interview, medical record review, and policy review, the facility failed to properly administer medications. This affected one resident (#10) of three residents reviewed for medications. The facility census was 34. Findings include: Review of the medical record for Resident #10 revealed an admission date of 03/31/23. Diagnoses included Alzheimer's disease, severe protein-calorie malnutrition, acute embolism and thrombosis of deep veins of right lower extremity, cellulitis of right lower limb, chronic pain syndrome, dementia, and hemiplegia and hemiparesis following cerebral infarction the affecting right dominant side. Review of the Minimum Data Set (MDS) 3.0 assessment for Resident #10, dated 04/07/23, revealed the Brief Interview for Mental Status (BIMS) score of 06, which indicated the resident was severely cognitively impaired. The assessment revealed there were no behaviors or rejection of care. The resident required extensive, two-person physical assistance for bed mobility, transfers, toileting, and dressing. Review of the plan of care for Resident #10…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-19 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on beneficiary protection notification review and staff interview, the facility failed to ensure residents discharged from skilled services were provided appropriate notification of services ending. This affected one Resident (#5) of three Residents reviewed for beneficiary protection notification. The facility census was 41. Findings include: Review of Resident #5's Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form indicated the resident's last covered day of Part A services was on 12/09/22. The form indicated the SNF Advanced Beneficiary Notice (ABN) Form CMS-10055 was not provided to Resident #5 or their responsible party. Interview with the Administrator on 01/18/23 at 1:50 P.M. verified the SNF ABN Form CMS-10055 was not provided due to she was on vacation and the social services designee was new to the position and unaware of the requirement.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-19 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to hold quarterly plan of care meetings for Resident #24 for the developement of and updates to the plan of care for Resident #24. This affected one out of one resident reviewed for care conferences. The facility census was 41. Findings include: Review of Resident #24's medical record revealed an admission date 01/14/22. Diagnoses included hallucinations, weakness, hypertension, and chronic obstructive pulmonary disease (COPD). Review of Resident #24's quarterly Minimum Data Set 3.0 assessment, dated 10/19/22, revealed the resident had intact cogitation. Interview on 01/17/23 at 8:56 A.M. Resident #24 revealed she doesn't believe she has had a care conference meeting and hasn't participated in her care planning. Review of a yearly look back of care conferences from admission through 01/2022 revealed Resident #24's last care conference was on 05/19/22. Interview on 01/17/23 at 3:25 P.M. the Administrator confirmed Resident #24's last care conference was on 05/19/22. She continued it was her expectation care conferences were to…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-01-19 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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 record review, interview, and policy and procedure review, the facility failed to follow the bowel protocol when Resident #9 went five days without a bowel movement. This affected one Resident (#9) out of five Residents reviewed for bowel elimination. The facility also failed to notify the physician when Resident #26 gained three to five pounds in one day. This affected one Resident (#26) out of six Residents reviewed for weights. The facility census was 41. Findings include: 1. Review of the medical record revealed Resident #9 was admitted on [DATE] with diagnoses that included type two diabetes mellitus, chronic kidney disease, and acute/chronic respiratory failure. The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #9 was cognitively intact. The resident required extensive assistance of one for bed mobility and total dependence of one for toilet use. Resident #9 was always continent of bowel. Review of the documentation for bowel movements revealed Resident #9 did not…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-19 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, family interview, medical record review and staff interview the facility failed to provide care and services to prevent worsening of identified joint contractures. This affected one Resident (#11) of one Resident reviewed for range of motion services. The facility census was 41. Findings include: Observation of Resident #11 on 01/17/23 at 8:30 A.M. and again at 3:40 P.M. identified contractures to the bilateral elbows and bilateral wrists. No evidence of any splint or brace device was observed in place at this time. Interview with Resident #11's power of attorney (POA) on 01/17/23 at 2:40 P.M. revealed Resident #11 had impaired movement to multiple joints for several years. Resident #11's POA was unaware of any services provided for the residents joint movement limitation other than some therapy at times. Review of Resident #11's medical record revealed an admission date of 03/28/11 with admission diagnoses that included contractures, traumatic brain injury and hypertension. Review of a restorative nursing assessment completed on 06/27/22 identified multiple…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-01-19 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to provide a proper indication for Resident # 32's Depakote use. This affected one Resident (#32) out of five Residents reviewed for unnecessary medications. The facility census was 41. Findings include: Review of Resident #32's medical record revealed an admission date of 09/02/22. Diagnoses included diabetes mellitus type two, atrial fibrillation, hypertension, obesity, and congestive heart failure. Continued review revealed the resident did not have a diagnosis of a seizure disorder or a psychiatric disorder. Review of Resident #32's Minimum Data Set 3.0 assessment, dated 01/07/23, revealed the resident had impaired cogitation. Review of Resident #32's admission orders revealed orders for Divalproex Sodium (Depakote) tablet Delayed Release (DR) 500 milligrams (mg) by mouth at bedtime for behaviors and Divalproex Sodium DR 250 MG by mouth two times a day for behaviors. Review of the resident's most recent physician's orders, dated 01/2023, revealed current orders for Depakote Sprinkles Capsule DR Sprinkle 125 mg with…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-19 · tag F0773 — isolated
    Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on medical record review and staff interview, the facility failed to ensure physician ordered laboratory testing was obtained and completed as ordered. This affected one Resident (#21) of five Residents reviewed for medication use. The facility census was 41. Findings include: Review of Resident #21's medical record revealed an admission date of 09/08/22 with admission diagnoses that included pneumonia, chronic obstructive pulmonary disease, diabetes mellitus and hypothyroidism. Further review of the medical record revealed on 09/20/22 the physician ordered the following laboratory testing including base metabolic profile (BMP), hemoglobin A1c, (HgbA1c), complete blood count (CBC) and thyroid stimulating hormone level (TSH). Review of the medical record found no evidence the laboratory testing was completed and obtained as ordered. Interview with the Director of Nursing on 01/18/23 at 9:50 A.M. verified the ordered laboratory testing was not completed and obtained for Resident #21 as ordered by the physician.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-05-07 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and policy review the facility failed to ensure a physician ordered pressure ulcer treatment was implemented timely for Resident #6. This affected one resident (#6) of three residents reviewed for pressure ulcers. Findings include: Review of Resident #6's medical record revealed an admission date of 05/02/18 with diagnoses including Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle) to the sacrum, obesity, paraplegia, peripheral vascular disease and diabetes mellitus. Review of a bi-weekly skin check dated 12/24/20 revealed the resident had a Stage IV pressure ulcer to his sacrum but no alteration to his right heel. Review of the nursing progress notes revealed the resident had a hospital stay from 12/29/20 through 01/03/21. Upon his return from the hospital on [DATE], the return skin check identified an unstageable (full thickness tissue loss in which actual depth of the ulcer is obscured by eschar (dark, dead tissue) or slough (yellow,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-05-07 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and staff interview, the facility failed to ensure the prescribing physician provided resident specific rationale for declining pharmacy review recommendations, acted upon pharmacy recommendations timely and/or identified missed laboratory studies. This affected three resident (#9, #14 and #24) of five residents reviewed for unnecessary medication use. Findings include: 1. Review of Resident #14's medical record revealed an admission date of 07/20/20 with diagnoses that included Alzheimer's disease with dementia, anxiety, major depression and psychotic disorder. Review of the monthly pharmacy review and recommendations revealed on 02/03/21 a recommendation to attempt a gradual dose reduction of both Seroquel and Risperdal (antipsychotic medications). On 03/26/21, the physician declined the recommendation, but did not provide any resident specific rationale for declining. On 05/05/21 at 11:20 A.M. interview with Registered Nurse (RN) #200 verified the pharmacy recommendation for Resident #14 was not acted upon timely and did not include a resident specific…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-05-07 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview the facility failed to ensure Resident #9, who received routine diuretic medication had laboratory testing completed as ordered to monitor for the effectiveness and correct dosage of the medication and to monitor the resident's potassium level. This affected one resident (#9) of five residents reviewed for unnecessary medication use. Findings include: Review of Resident #9's medical record revealed an admission date of 02/10/18 with diagnoses including asthma, hypertension and shortness of breath. Review of the physician's medication orders revealed an order, dated 11/20/20 for Torsemide (a diuretic) 20 milligrams give two tablets daily for edema. On 01/21/21 an order was obtained for Metolazone (a diuretic) five mg once a day. Both medications have the potential to cause electrolyte imbalances. Review of the physician's orders revealed an order for laboratory testing, including a weekly metabolic panel (BMP), initiated 11/23/20. Review of the laboratory testing results revealed no BMP had been completed from February 2021 through 04/14/21. 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-05-07 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement 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

    Based on record review and staff interview the facility failed to appropriately monitor Resident #14 who received psychotropic medications for resident specific behaviors. This affected one resident (#14) of five residents reviewed for unnecessary medication use. Findings include: Review of Resident #14's medical record revealed an admission date of 07/20/20 with diagnoses that included Alzheimer's disease with dementia, anxiety, major depression and psychotic disorder. Review of the physician medication orders revealed an order for Seroquel (antipsychotic medication) 25 milligrams (mg) in the morning and 50 mg at night and Remeron (antidepressant medication) 7.5 mg every night. Review of the plan of care for Resident #14 revealed care plans in place for antipsychotic and antidepressant therapy. The antidepressant care plan interventions included monitor for suicidal ideations and medication side effects. However, no specific resident behaviors were identified. The antipsychotic therapy care plan interventions included monitor and report target behavior symptoms but were not…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-05-07 · tag F0803 — failed to meet residents' dietary needs — isolated
    Ensure 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, record review, menu review, diet card review and interview the facility failed to ensure Resident #9 was provided a diet as ordered. This affected one resident (#9) of 12 residents who received meals on the south wing meal cart. The facility census was 31. Findings include: Review of Resident #9's medical record revealed a physician order dated 03/09/21 for double protein (for each meal). Review of the 05/05/21 lunch menu revealed the planned menu included three ounces of savory pork roast, pork gravy, au gratin potatoes, braised cabbage and mud pie On 05/05/21 at 11:53 A.M. Dietary Supervisor (DS) #105 was observed to plate Resident #9's lunch meal which consisted of one slice of savory pork roast with gravy, au gratin potatoes, cabbage, mud pie and bread with butter. Review of the resident's meal card/tray ticket revealed the resident was to receive double protein with meals. On 05/05/21 at 11:56 A.M. DS #105 informed Dietary [NAME] (DC) #128 the trays were ready to be taken to the floor and DC #128 began to push the trays from the steam table area. 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to SABER HEALTHCARE GROUP — 126 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 52.9+0.1 vs chain
Health inspection 3 of 52.6+0.4 vs chain
Staffing 1 of 52.2-1.2 vs chain
Quality measures 5 of 54.0+1.0 vs chain
The other 125 homes this chain runs (chain average 2.9★, per CMS)
1 of 5Autumn Care of MarshvilleMarshville, NC 1 of 5Autumn Care of Myrtle GroveWilmington, NC 1 of 5Autumn Care of WaynesvilleWaynesville, NC 1 of 5Brunswick Health & Rehab CenterAsh, NC 1 of 5Bryn Mawr Extended Care CenterBryn Mawr, PA 1 of 5Caring Heights Community Care & Rehab CtrCoraopolis, PA 1 of 5Colonial Health & Rehab Center, LLCVirginia Beach, VA 1 of 5Currituck Health & Rehab CenterBarco, NC 1 of 5Davidson Health & Rehab CenterLexington, NC 1 of 5Edison Manor Nursing & Rehabilitation CenterNew Castle, PA 1 of 5Gastonia Health & Rehab CenterGastonia, NC 1 of 5Greene Health & Rehab CenterGreensburg, PA 1 of 5Grey Stone Health And Rehabilitation CenterFort Wayne, IN 1 of 5Harmar Village Health & Rehab CenterCheswick, PA 1 of 5Highland Pointe Health & Rehab CenterHighland Heights, OH 1 of 5Hilltop Heights Health & Rehab CenterJohnstown, PA 1 of 5Maple Heights Health & Rehab Center, LLCEbensburg, PA 1 of 5Midtown Oaks Health & Rehab CenterAltoona, PA 1 of 5Mountain City Nursing & Rehabilitation CenterHazleton, PA 1 of 5Providence Health & Rehab CenterBeaver Falls, PA 1 of 5River's Bend Health & Rehab CenterHarrisburg, PA 1 of 5Riverside Health & Rehab CenterMcKeesport, PA 1 of 5South Boston Health & Rehab CenterSouth Boston, VA 1 of 5Tallmadge Health & Rehab CenterTallmadge, OH 1 of 5University Manor Health & RehaCleveland, OH 1 of 5Village Care of KingKing, NC 1 of 5Woodhaven Health & Rehab CenterMonroeville, PA 1 of 5Woodlands Health And Rehab CenterRavenna, OH 2 of 5Aurora Manor Special Care CentAurora, OH 2 of 5Autumn Care Of MadisonMadison, VA 2 of 5Autumn Care Of MechanicsvilleMechanicsville, VA 2 of 5Autumn Care Of SuffolkSuffolk, VA 2 of 5Autumn Care of CorneliusCornelius, NC 2 of 5Autumn Care of RaefordRaeford, NC 2 of 5Autumn Care of SaludaSaluda, NC 2 of 5Autumn Care of ShallotteShallotte, NC 2 of 5Azalea Health & Rehab CenterWilmington, NC 2 of 5Bath Manor Special Care CentreAkron, OH 2 of 5Berea Health & Rehab CenterFredericksburg, VA 2 of 5Broad Mountain Health And Rehabilitation CenterFrackville, PA

Showing 40 of 125; lowest-rated first.

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleSince
VOLPE, BENJAMINIndividualCORPORATE DIRECTOR; CORPORATE OFFICER; ADP OF THE SNFsince 03/01/2019
WEISBERG, WILLIAMIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 11/01/2002
NICOLUZAKIS, GREGORYIndividualCORPORATE OFFICER; ADP OF THE SNFsince 03/01/2019
SHG MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/01/2019
HOHLEFELDER, JASONIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/02/2024
WEBER, KELLIIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/01/2021
AMBERWOOD RE GROUP, LLCOrganizationADP OF THE SNFsince 06/01/2018
CITRIN COOPERMAN ADVISORS LLCOrganizationADP OF THE SNFsince 11/01/2002
SABER GOVERNANCE LLCOrganizationADP OF THE SNFsince 09/01/2019
JONES, RICHARDIndividualADP OF THE SNFsince 04/01/2019

CMS files one row per role, so the 17 rows in the source record cover these 10 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.

4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$3.1M
Net patient revenuemost recent cost report
-37.4%
Operating marginrevenue minus expenses
$1.0M
Related-party expense24% of expenses
Who pays — share of resident-days
Medicaid 71%Medicare 3%Other / private 26%

About 71% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.0M paid to related parties — landlords or management companies under common ownership — equal to about 24% 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

$329per resident / day
operating cost
$10,007per month
≈ monthly operating cost
$240per day
avg. revenue, all payers

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

What families pay in OH

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 366253. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-01-23, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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