No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Riverside Manor Nrsg & Rehab Ctr

1100 East State Road, Newcomerstown, OH 43832 · For profit - Corporation · 80 certified beds · (740) 498-5165 Medicare & Medicaid certified

Call the home — (740) 498-5165 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Dec 20251 actual-harm citation
Insights

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

In its favor
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (22% vs 45% nationally) — better care continuity
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Dec 2025
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (2/5)

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

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

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 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 staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
232 Cross St
Pharmacy
245 W State St · (740) 498-6337 · Call to confirm hours
Grocery
316 S College St · (740) 498-4155 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship

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
Short-stay residentsrehab / post-hospital 3 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 fell from 5 to 3 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 rating3★
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 increased3.1%5.3%15.4%better than state — see note marked double-dagger below the table
Long-stay residents who lose too much weight4.5%6.2%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.2%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection2.5%0.4%2.0%worse than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms2.6%30.1%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury5.4%3.2%3.3%worse
Long-stay residents whose ability to walk worsened3.1%6.1%16.1%better than state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication19.5%25.5%18.9%typical
Long-stay residents given the seasonal flu vaccine95.1%94.5%95.3%typical
Long-stay residents with pressure ulcers2.4%3.4%4.7%better
Long-stay residents with worsening bladder/bowel control24.1%21.4%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table1.8%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 vaccine93.4%75.6%79.4%better
Short-stay residents rehospitalized after admission35.7%24.9%22.6%worse
Short-stay residents with an outpatient ER visit7.9%12.9%12.0%better

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.

58.1% 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 85 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

58.1%U.S. median 51.5%
Got home and stayed home
9.8%U.S. median 10.7%
Went back to hospital
45.2%U.S. median 56.6%
Met the expected recovery
0.32U.S. median 0.31
Therapy hours / resident / day
0.15hours / resident / day
Physical therapy
0.11hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 45.2% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 31 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.32 therapist hours per resident per day in 2026Q1 — more than 53% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 6% 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 SNF58.1%CMS range 47.7–67.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.8%CMS range 7.3–13.810.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge45.2%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge35.5%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge25.8%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this 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 stay1.8%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 worsened5.5%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.3%CMS range 3.4–12.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.961.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.63
RN hours/ resident / day
0.92
LPN hours/ resident / day
3.00
Aide hours/ resident / day
4.55
Total nurse hours/ resident / day
0.51
RN hoursweekends
21.8%
Total nursing turnover
41.7%
RN turnover

How full it usually is: this home is certified for 80 beds and averages 69.5 residents a day — about 87% occupied, or roughly 10 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 4.55 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.63 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.00 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 4.00 hrs/resident/day on weekends vs 4.77 on weekdays — 16% thinner on weekends. RN hours go from 0.67 to 0.51 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 22% is below the national median of 45%.

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

Inspection trend

14
deficiencies at the latest standard inspection (2025-01-30)
7
at the previous standard inspection (2024-03-07)

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.

27 citations, most serious first. The 11 most serious are shown; the remaining 16 are one tap away and print in full.

  • Actual harm · Gcited before2026-04-24 · 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, review of therapy records, review of the facility's investigation, review of employee conference reports, and interviews with resident(s), family, and staff, the facility failed to ensure a resident was transferred safely following physical therapy recommendations. This resulted in Actual harm on 04/12/26 when Resident #1 was improperly transferred resulting in a fractured arm. This affected one (#1) of three residents reviewed for accidents and injuries.Findings include:Medical record review revealed Resident #1 was originally admitted to the facility 05/06/25 and re-admitted on [DATE] with diagnoses that included displaced fracture of base of neck of right femur, nondisplaced fracture of surgical neck of right humerus, anemia, orthopedic aftercare, restless legs, heart failure, kidney disease, and hyperlipidemia. Review of Resident #1's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was admitted [DATE] with diagnoses including heart failure, renal disease, and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-04 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of a self-reported incident (SRI), interviews and policy review, the facility failed to ensure Resident #19 was free from verbal abuse. This affected one (Resident #19) out of three residents reviewed for abuse. The facility census was 70.Findings include:Review of the medical record revealed Resident #19 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia and hemiparesis, dementia, anxiety, bipolar disorder, and schizophrenia. Review of the care plan dated 01/09/25 revealed Resident #19 had a behavior of yelling in the common area and in her room. Interventions included to return Resident #19 to her room after meals; if the resident is screaming, offer her favorite snacks ([NAME] Bar or potato chips); ask the resident if she would like to lie down in bed; and approach in a cheerful way. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had a Brief Interview for Mental Status (BIMS) score of nine out of…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-04 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    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 a self-reported incident (SRI), interviews, and policy review, the facility failed to ensure Resident #18 was not restrained in a wheelchair without adequate training, assessments, and orders. This affected one (Resident #18) out of three residents reviewed for abuse. The facility census was 70.Findings include:Review of the medical record revealed Resident #18 was admitted on [DATE] with diagnoses that included dementia, history of transient ischemic attack, down syndrome, type 2 diabetes, and dysphagia.Review of the plan of care dated 02/20/25 revealed Resident #18 had the potential for injury related to poor decision-making skills. An intervention dated 06/06/25 for the resident to have a custom fitted wheelchair with adaptations for safety when in chair to be delivered after measured and approved by Medicaid. Review of a general progress note dated 06/02/25 at 6:00 A.M. revealed Resident #18 was on the floor in front of the chair. The resident had red drainage noted from the…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-04 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of self-reported incidents (SRI), interviews and policy review, the facility failed to ensure allegations of verbal abuse by staff towards Resident #19 were immediately reported. This affected one (Resident #19) out of three reviewed for abuse. The facility census was 70.Findings include:Review of the medical record revealed Resident #19 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia and hemiparesis, dementia, anxiety, bipolar disorder, and schizophrenia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had a Brief Interview for Mental Status (BIMS) score of nine out of 15 which indicated cognitive impairment. Resident #19 had verbal behaviors one to three days during the seven-day assessment period. Review of SRI tracking #263082 dated 07/22/25 at 2:49 P.M. revealed Resident #19 was sitting in the dining room with other residents getting ready to eat lunch. Resident #19 began screaming. Certified…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-01-30 · tag F0926 — failed to keep the home smoke-free / fire-safe — widespread
    Have policies on smoking.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview with staff, and review of the facility policy, the facility failed to maintain a safe and clean environment free from discarded cigarette butts in the resident smoking area. This had the potential to affect all residents residing in the facility. The facility census was 62. Findings include: Observation on 01/27/25 at 11:15 A.M. the resident smoking area with Housekeeper #201 revealed several cigarette butts on the concrete pad under the awning and in the stones by the building where the residents smoked. There were several leaves laying around the area which could catch on fire. Interview on 01/27/25 at 11:20 A.M. with Housekeeper #201 confirmed the cigarettes were not discarded properly in the fireproof container. Review of the undated policy titled, Smoking/Electronic Cigarettes revealed the purpose was to educate all staff and residents on the policy and procedure in regard to smoking and electronic cigarettes. The policy made no mention of proper discarding of cigarettes. Review of the undated policy Staff Smoking revealed cigarettes were to be…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-30 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of employee disciplinary conference report, review of staff schedules, resident interview, staff interview, and policy review, the facility failed to ensure resident concerns with personal care were addressed timely. This affected one (Resident #5) of four reviewed for abuse. Findings included: Medical record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including schizophrenia, dementia with psychotic disturbance, depression, coronary artery dissection, Alzheimer's, allergic rhinitis, constipation, ulcerative colitis, anxiety, insomnia, chronic kidney disease, heart disease, mood disorder, gout, gastro-esophageal reflux, hyperlipidemia, hypothyroidism, overactive bladder, sleep apnea, Parkinsonism, anemia, and atrial fibrillation. Review of the care plan dated 03/28/24 for Resident #5 revealed the resident had an alteration in bowel function related to needing assistance with mobility with interventions that the resident was 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-30 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, review of the facility investigation, resident interview, staff interview, and review of facility policy and procedure, the facility failed to ensure Resident #6 was not abused by a staff member. This affected one resident (Resident #6) of four residents reviewed for abuse. Findings included: Review of the medical record revealed Resident #6 was admitted to the facility on [DATE]. Diagnoses included hypertensive heart disease, depression, vitamin D deficiency, anxiety disorder, cirrhosis of the liver, malignant neoplasm of the large intestine, diabetes, heart failure, osteoarthritis of the hip, atrial fibrillation, lymphedema, adrenocortical insufficiency, and insufficiency. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #6 had intact cognition. Review of the progress note dated 09/11/24 at 8:45 P.M. revealed a Certified Nursing Assistant (CNA) #210)) was assisting Resident #6 in the shower when the resident started to get loud with the…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-30 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of medical records, resident interview, representative interview, and staff interview, the facility failed to ensure residents and/or resident representatives were provided a written summary of the baseline care plan. This affected two (Residents #61 and #165) of six residents reviewed for baseline care planning. Findings include: 1. Review of Resident #61's medical record revealed an admission date of 11/26/24 with diagnoses including displaced fracture of the base of the neck of the right femur, depression, vitamin D deficiency, hyperlipidemia, hypertension, diabetes mellitus and displaced fracture of the surgical neck of the left humerus. The medical record revealed no indication that Resident #61 or her representative were provided a summary of the baseline care plan. Interview on 01/27/25 at 10:28 A.M., Resident #61's representative revealed he did not recall receiving a summary of the plan of care. Interview on 01/30/25 at 7:17 A.M., the Director of Nursing (DON) verified she was unable to locate evidence that a summary of the baseline care plan was provided 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 · D2025-01-30 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and medical record review, the facility failed to ensure comprehensive care plans were revised timely. This affected two residents (Residents #10 and #61) of 24 residents reviewed for care plans. The facility census was 62. Findings include: 1. Review of the medical record for Resident #10 revealed an admission date of 10/24/22. Diagnoses included hemiplegia affecting the left side, actinic keratosis, bipolar disorder, chronic obstructive pulmonary disorder, peptic ulcer disease diabetes, anxiety disorder, osteoarthritis, benign prostatic hyperplasia, chronic pain, insomnia, hypertension, atherosclerotic heart disease, major depressive disorder, cerebrovascular disease, and paralytic syndrome. Review of the plan of care dated 10/27/22 revealed Resident #10 was a smoker and required a smoking apron. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #10 had intact cognition and had one side upper extremity impairment. Review of the…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-30 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview, observation, and review of facility policy, the facility failed to ensure Resident #49 received assistance with oral care. This affected one (Resident #49) of four residents reviewed for activities of daily living. The facility census was 62. Findings include: Review of Resident #49's medical record revealed an admission date of 12/19/24 with diagnoses including diabetes, severe protein-calorie malnutrition, adult failure to thrive, kidney disease, gastro-esophageal reflux, weakness, and heart disease. Review of Resident #49's Minimum Data Set (MDS) dated [DATE] revealed the resident was dependent on staff for oral care. There was no evidence of refusals or rejection of care. Review of Resident #49's interdisciplinary team (IDT) progress note dated 01/17/25 revealed the resident required set up assistance for oral hygiene. Review of Resident #49's care plan indicated the resident had an alteration in dental status related to own teeth. The resident's plan of care 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-30 · 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 observations, record review, interview, and review of facility policy, the facility failed to ensure residents with non-pressure related skin issues were comprehensively assessed and treated in a routine manner. This affected two (Residents #51 and #165) of two residents reviewed for non-pressure related skin impairment. The facility census was 62. Findings include: 1. Review of Resident #165's medical record revealed an admission date of 01/01/25. Medical diagnoses included malignant neoplasm of the right ovary, methicillin resistant staphylococcus aureus (MRSA), adult failure to thrive, diabetes mellitus type two, anemia, and fistula of the intestine. A pre-admission hospital history and physical dated 12/25/24 indicated an abdominal drain in the right lower quadrant of the abdomen had accidentally been pulled out ten days previous. A Computed Tomography (CT) scan showed a complex right cystic lower abdominal intraperitoneal mass likely ovarian origin which appeared to have a fistula tract through 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 16 citations
  • Potential for harm · D2025-01-30 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and interviews, the facility failed to ensure splints/braces were applied per orders and plan of care. This affected one (Resident #18) of one resident reviewed for positioning/mobility. The facility census was 62. Findings include: Review of Resident #18's medical record review revealed an admission date of 08/02/22 with diagnoses including Parkinsonism, chronic pain, rhabdomyolysis, and limited range of motion. Review of Resident #18's Minimum Data Set (MDS) dated [DATE] revealed the resident had impaired range of motion to bilateral upper extremities. The resident had no rejection/refusal of care. Review of Resident #18's active physician's orders revealed an order dated 02/12/24 to apply wrist braces daily at 8:00 A.M. and remove daily at 8:00 P.M. The order indicated the braces could be removed for meals. The order did not specify which wrist, or both, the brace/braces should be applied to. An additional order dated 05/13/24 stated to place finger splints on left…

    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 before2025-01-30 · 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 observation, interview, medical record review, and review of the facility policy, the facility failed to ensure fall interventions were in place for a resident at risk for falls. This affected one (Resident #42) of three residents reviewed for accidents. The facility census was 62. Findings include: Review of the medical record revealed an admission date of 12/16/24. Diagnoses included Alzheimer's disease, anxiety disorder, paroxysmal atrial fibrillation, type two diabetes mellitus, hypertension, chronic lung disease and depression. Review of the Minimum Data Set (MDS) 3.0 significant change assessment dated [DATE] revealed Resident #42 had a Brief Interview for Mental Status (BIMS) Score of 5, indicating severely impaired cognition. Resident #42 was assessed to require assistance with activities of daily living (ADLs) including setup for eating and oral care and hands-on assistance with bathing, dressing, and transfers. Resident #42 used a wheelchair for mobility. Further review revealed the resident…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-30 · 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

    Based on observation, interview, and review of facility policy, the facility failed to ensure multi-dose insulin pens were dated as to when they were first accessed. This affected two residents (Resident #32 and #166) out of 11 residents identified by the facility as receiving insulin injections. The facility census was 62. Findings include: Observation on 01/27/25 at 11:20 A.M. of the rehabilitation hall medication cart with Licensed Practical Nurse (LPN) #158 revealed two multi-dose insulin pens were accessed but were not dated as to when they were first opened and accessed. The two pens were Resident #32's Glargine Solostar (insulin) 100-unit pen and Resident #166's Tresiba (insulin) 200-unit pen. Interview on 01/27/25 at 11:30 A.M. with LPN #158 confirmed the two multi-dose insulin pens were not dated as to when they were first opened and accessed. An interview on 01/30/25 at 10:26 A.M. with the Director of Nursing (DON) revealed all insulin was to be dated when accessed for the first time. Review of the facility policy titled, Multi-dose Pens of Injectable Medications, 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-30 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, psychiatrist billing list, and interview, the facility failed to ensure residents records were complete and included in-house psychiatric progress notes and Nurse Practitioner (NP) notes. This affected two (Resident #5 and #18) of five residents reviewed for unnecessary medications. The facility census was 62. Findings include: 1. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including schizophrenia, dementia with psychotic disturbance, depression, coronary artery dissection, Alzheimer's disease, allergic rhinitis, constipation, ulcerative colitis, anxiety, insomnia, chronic kidney disease, heart disease, mood disorder, gout, gastro-esophageal reflux, hyperlipidemia, hypothyroidism, overactive bladder, sleep apnea, Parkinsonism, anemia, and atrial fibrillation. Review of the psychiatrist billing list dated 01/17/24 to 12/20/24 revealed Resident #5 was seen by the psychiatrist on 09/25/24, 10/23/24, and 11/20/24. Review of Resident…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-30 · tag F0881 — failed to use antibiotics responsibly — isolated
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, policy review, and interview, the facility failed to ensure antibiotics were utilized only when medically necessary. This affected one (Resident #61) of two residents reviewed for antibiotic use. The facility census was 62. Findings include: Review of Resident #61's medical record revealed an admission date of 11/26/24 and diagnoses including urinary tract infection, fracture of the surgical neck of the left humerus (long bone in the arm that runs from the shoulder to the elbow), and diabetes mellitus. Resident #61 was sent to the hospital 12/12/24 for an acute fracture of the proximal right femur (thigh bone). Resident #61 returned to the facility 12/14/24 with orders for Doxycycline (antibiotic) 100 milligrams (mg) twice a day for post-operative infection prevention to the right hip for a total of 19 administrations. A nursing progress note dated 12/15/24 at 7:05 P.M. indicated an unnamed Certified Nursing Assistant (CNA) alerted the nurse Resident #61's urine was dark colored. Resident #61 complained of her bladder burning. A nursing progress note…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-07 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    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 observations, interviews, and policy review, the facility failed to ensure allegations of missing items were resolved to residents' satisfaction. This affected three (Residents #10, #20, and #36) of 12 residents interviewed regarding personal property. The facility census was 65. Findings include: 1. Review of Resident #20's medical record revealed diagnoses including major depressive disorder, dementia, and anxiety disorder. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #20 was able to make herself understood, was able to understand others, and was cognitively intact. During an interview on 03/04/24 at 9:13 A.M., Resident #20 reported she was missing two pairs of gray jogging pants and a black nightshirt with the saying dogs are my favorite people. Resident #20 stated she received the items for Christmas and her name was marked in the items. Although staff had said they looked for the missing items, they had been gone for a while and she had not heard anything. On…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-07 · 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, observation, interviews, and policy review the facility failed to ensure skin alterations were identified and treated timely and failed to ensure hospice records were available to ensure continuity of care. This affected one (Resident #4) of one reviewed for non-pressure skin alterations and one (Resident #29) of one reviewed for hospice services. The facility census was 65. Finding included: 1. Record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including type two diabetes with polyneuropathy, congestive heart failure, glaucoma, muscle weakness, difficulty walking, and unsteadiness on feet. Review of Resident #4's medical record dated 02/01/24 to 03/05/24 revealed no evidence of skin alterations or treatments to the resident's left foot or bilateral shins. Review of the facility's wound book revealed no evidence Resident #4 had a skin sheet for skin alterations to the left foot or bilateral shins. Observation and interview on 03/04/24 at 9:00 A.M.,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-07 · 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

    Based on medical record review, observation and staff interview, the facility failed to compressively assess, document wounds upon discovery and to ensure weekly skin assessments were completed as ordered by the physician. This affected one (Resident #33) of two residents reviewed for skin conditions. The facility census was 65. Findings include: Review of Resident #33's medical record revealed an admission date of 05/04/18 with diagnosis that included Alzheimer's disease with dementia, hypertension and osteoporosis. Further review of the medical record including pressure ulcer wound risk assessments completed on 07/18/23 indicated Resident #33 was at very high risk of pressure ulcer wound development. Review of the medical record including wound assessments revealed on 09/22/23 a wound was discovered on the coccyx of Resident #33. Further review of the wound assessments, from onset on 09/22/23 through 02/28/24, revealed no staging of the wound completed. The wound measured 2.2 centimeters (cm) by 1.0 cm and 0.1 cm deep. Review of the nursing notes for Resident #33 revealed no…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review and staff interview the facility failed to complete elopement risk assessments for a resident displaying exit seeking behaviors. This affected one (Resident #43) of one residents reviewed for elopement risk. The facility census was 65. Findings include: Review of Resident #43's medical record revealed an admission date of 05/31/23 with diagnoses that included Alzheimer's disease with dementia and cerebrovascular accident. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment with a reference date of 12/04/23 revealed Resident #43 had a severely impaired cognition level, utilized a walker for mobility and was supervision assistance only with ambulation. Further review of the medical record including nursing notes revealed wandering and exit seeking behaviors documented as displayed on 02/20/24, 02/19/24 twice, 02/15/24 twice, 02/14/24, 02/09/24, 02/08/24, 02/05/24, 01/11/24, 01/05/24, 12/11/23, 12/11/23 and 10/22/23. Review of the medical record revealed no evidence of any elopement risk assessment completed for the resident or elopement risk…

    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 · D2024-03-07 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview, and policy review the facility failed to ensure a resident received appropriate antibiotic treatment and initiate practitioner ordered intervention when the resident continued exhibiting urinary symptoms. The facility also failed to ensure a resident received restorative bladder training when noted to have a moderate restorative potential. This affected one (Resident #4) of one reviewed for urinary tract infection and one (Resident #36) of one reviewed for bowel and bladder incontinence. The census was 65. Findings included: 1. Record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including type two diabetes mellitus, stress incontinence, urge incontinence, weakness, and difficulty walking. Review of Resident #4 quarterly MDS dated [DATE] revealed the resident was always incontinent of bladder and bowel and cognition was intact. Review of Resident #4's alteration of urinary system plan of care related to needs assistance with mobility…

    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 · D2024-03-07 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review and interview, the facility failed to ensure medications were administered to a resident receiving dialysis services in accordance with physician services. This affected one (Resident #47) of one resident reviewed for dialysis. The facility identified one resident receiving dialysis services. The facility census was 65. Findings include: Review of Resident #47's medical record revealed diagnoses including dependence on renal dialysis and stage three chronic kidney disease. A care plan initiated 12/11/23 indicated Resident #47 received dialysis three days a week (Tuesday, Thursday, and Saturday). Review of a physician order revealed an active order dated 12/16/23 with instructions to hold all blood pressure medications before dialysis. Review of the January 2024 to March 2024 Medication Administration Records (MARs) revealed the blood pressure medications (Norvasc and metoprolol succinate extended release) were not held prior to dialysis treatments. On 03/06/24 at 9:57 A.M. the Director of Nursing (DON) verified nurses were administering blood pressure…

    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 before2024-03-07 · tag F0881 — failed to use antibiotics responsibly — isolated
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of the infection control log, interview, and policy review the facility failed to ensure residents met criteria for antibiotic treatment. This affected one (Resident #4) of one reviewed for UTI and one (Resident #36) of one reviewed for bowel and bladder incontinence. The facility census was 65. Findings included: 1. Record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including type two diabetes mellitus, stress incontinence, urge incontinence, weakness, and difficulty walking. Review of Resident #4 quarterly MDS dated [DATE] revealed the resident was always incontinent of bladder and bowel and cognition was intact. Review of Resident #4's alteration of urinary system plan of care related to needs assistance with mobility revealed the resident was dependent on assistance with toileting hygiene and monitor and report additional signs and symptoms of infection. Review of Resident #4 progress notes revealed on 02/24/24 at 11:29 A.M.…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-06-30 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure Minimum Data Set (MDS) assessments were accurate. This affected four residents (#40, #6, #37, and #4) of four reviewed for accuracy of MDS assessments. The facility census was 62. Findings include: 1. Review of the medical record for Resident #40 revealed an admission date of 02/10/22 with diagnoses including dementia with behavioral disturbance, anxiety disorder, and hypertension. Review of the quarterly MDS assessment dated [DATE] revealed the resident had severe cognitive impairment. The assessment indicated a wander/elopement alarm was not used and wandering was not exhibited. Review of the progress notes 05/13/22 at 2:04 P.M., 05/16/22 at 3:58 P.M., 05/17/22 at 3:40 P.M., 05/17/22 at 4:09 P.M., 05/18/22 at 4:13 P.M., and 05/18/22 at 9:42 P.M. revealed the resident exhibited wandering and exit seeking behaviors. Review of the physician's orders for June 2022 identified orders for a Wander Guard device (ordered 02/10/22). On 06/27/22 at 9:35…

    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 before2022-06-30 · 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 review of the medical record, observation and staff interview the facility failed to ensure Resident #18 and #27 were properly supervised in the dining room during meal time. This affected two residents (Resident #18 and #27) of seven observed for dining service. Findings include: Review of the medical record revealed Resident #27 was admitted to the facility on [DATE]. Diagnoses included myocardial infarction, respiratory failure, congestive heart failure, diabetes, urinary tract infection, asthma, COVID-19, hypotensive, chronic obstructive pulmonary disease, cataract, hypoxemia, sleep apnea, dysphagia (difficulty swallowing), dementia, macular degeneration, and anxiety disorder. Review of the Medical Nutrition Re-assessment dated [DATE] revealed Resident #27 ate in the dining room for supervision and assistance. She was on a mechanical soft diet. Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #27 had intact cognition and required supervision with eating. Further…

    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
  • No harm found · C2025-01-30 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview, the facility failed to ensure nurse staffing information was posted. This had the potential to affect all residents residing in the facility. The facility census was 62. Findings include: On 01/27/25 at 8:59 A.M., observations revealed the only staffing information posted was dated 01/24/25. On 01/27/25 at 8:59 A.M., Business Office Personnel #157 verified the information posted was dated 01/24/25. She was unaware who was responsible for posting the staffing information.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2025-01-30 · tag F0625 — pattern
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to provide a bed hold notice to Resident #61 who was hospitalized . This affected one (Resident #61) of two residents reviewed for hospitalization. Findings include: Review of Resident #61's medical record revealed an admission date of 11/26/24 and diagnoses including vitamin D deficiency, disorders of bone density and structure, diabetes mellitus, and displaced fracture of the surgical neck of the left humerus (long bone in the arm or forelimb that runs from the shoulder to the elbow). A discharge summary note dated 12/16/24 at 11:46 A.M. indicated Resident #61 participated well with therapy on 12/12/24, walking more than she ever did. Later in the day on 12/12/24, Resident #61 complained of groin pain. An x-ray indicated Resident #61 had a right hip fracture. Resident #61 was transferred to the emergency room for admission and surgical repair. Review of the discharge and transfer notice dated 12/12/24 revealed it was signed by Resident #61's spouse on 12/12/24. Further review of the medical record revealed no 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.

    Resident Rights 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.

Who owns this facility

Owner / managerTypeRoleShareSince
MORTINE, MARKIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST7%since 01/14/2022
MORTINE, NEILIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST7%since 01/14/2022
OURS, KENIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST12%since 03/01/2008
SHEPHERD, DWAYNEIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; W-2 MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF9%since 10/08/2008
SMITH, CLARKIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER; ADP OF THE SNF12%since 06/22/2014
BAMBECK, ALANIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 05/09/2007
COCHRAN, MICHAELIndividualCORPORATE OFFICERsince 10/21/2008
OVERHOLSER, TERRYIndividualCORPORATE OFFICERsince 05/08/1989
WELCH, JAMESIndividualCORPORATE OFFICERsince 09/01/2014

CMS files one row per role, so the 16 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.

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.

$5.6M
Net patient revenuemost recent cost report
-14.3%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 54%Medicare 8%Other / private 37%

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

$282per resident / day
operating cost
$8,561per month
≈ monthly operating cost
$246per 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 365429. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-01-30, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

What to do next