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O'neill Healthcare North Olmsted

4800 Clague Road, North Olmsted, OH 44070 · For profit - Corporation · 67 certified beds · (440) 734-9933 Medicare & Medicaid certified

Call the home — (440) 734-9933 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Resident-funds citation (F0569)1 actual-harm citation
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
Worth asking about
  • it has a citation for mishandling residents’ money or property (F0569)
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (20) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its payroll-based staffing rating is low (2/5)
  • 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.

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

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

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
24700 Lorain Rd · (440) 779-5505 · Call to confirm hours
Pharmacy
24646 Brookpark Rd · (440) 414-0010 · Call to confirm hours
Grocery
24005 Lorain Rd · (440) 716-6093 · Call to confirm hours
Park
24000 Valley Pkwy · (440) 734-6660 · Typically dawn to dusk
Place of worship
4242 Brendan Ln · (440) 777-7222

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 increased2.4%5.3%15.4%better than state — see note marked double-dagger below the table
Long-stay residents who lose too much weight2.4%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 infection0.0%0.4%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms81.2%30.1%6.5%worse 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 injury2.8%3.2%3.3%better
Long-stay residents whose ability to walk worsened2.6%6.1%16.1%better than state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication8.2%25.5%18.9%better
Long-stay residents given the seasonal flu vaccine77.5%94.5%95.3%worse
Long-stay residents with pressure ulcers1.6%3.4%4.7%better
Long-stay residents with worsening bladder/bowel control22.0%21.4%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table1.2%8.8%17.1%better
Short-stay residents who newly got an antipsychotic medication3.1%1.2%1.4%worse
Short-stay residents given the seasonal flu vaccine49.2%75.6%79.4%worse
Short-stay residents rehospitalized after admission32.4%24.9%22.6%worse
Short-stay residents with an outpatient ER visit9.3%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.

53.7% 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 186 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

53.7%U.S. median 51.5%
Got home and stayed home
11.5%U.S. median 10.7%
Went back to hospital
66.3%U.S. median 56.6%
Met the expected recovery
0.53U.S. median 0.31
Therapy hours / resident / day
0.28hours / resident / day
Physical therapy
0.23hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 66.3% 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 83 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 0.53 therapist hours per resident per day in 2026Q1 — more than 83% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 13% 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 SNF53.7%CMS range 46.4–61.451.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.5%CMS range 8.9–14.910.7%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 discharge66.3%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 discharge69.9%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 discharge56.6%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 identified98.2%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 setting93.2%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 discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this 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 worsened4.4%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 hospitalization7.5%CMS range 4.5–10.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.861.02Oct 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

0.71
RN hours/ resident / day
1.05
LPN hours/ resident / day
1.90
Aide hours/ resident / day
3.65
Total nurse hours/ resident / day
0.45
RN hoursweekends
53.7%
Total nursing turnover
66.7%
RN turnover

How full it usually is: this home is certified for 67 beds and averages 49.2 residents a day — about 73% occupied, or roughly 18 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.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.65 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.71 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.90 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.97 hrs/resident/day on weekends vs 3.93 on weekdays — 25% thinner on weekends — a notable drop. RN hours go from 0.81 to 0.45 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 54% 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

9
deficiencies at the latest standard inspection (2025-04-09)
4
at the previous standard inspection (2023-10-05)

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.

20 citations, most serious first. The 11 most serious are shown; the remaining 9 are one tap away and print in full.

  • Actual harm · Gcited before2025-04-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and facility policy review, the facility failed to ensure individualized care plan interventions were developed, updated, and initiated following falls for Resident #33 and Resident #36. The facility also failed to conduct thorough post-fall investigations with root cause analysis to ensure a comprehensive fall management program was in place for Resident #8, Resident #33 and Resident #36. This affected three residents (#8, #33, and #36) of three residents reviewed for accidents. The facility census was 57. Actual Harm occurred on 01/29/25 when Resident #33, who was identified as high risk for falls, had moderate cognitive impairment and required supervision or touching assistance with ambulation and partial to moderate assistance with toileting hygiene, was left unattended in the bathroom resulting in a fall with a left wrist fracture. Prior to this fall with injury, Resident #33 had a history of falls (03/24/24, 09/11/24, 10/20/24, and 12/05/24) without thorough…

    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 · E2025-04-09 · tag F0847 — pattern
    Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of the Arbitration Agreement and interviews the facility failed to ensure the resident or representative had the right to rescind the agreement within 30 calendar days after signing it. This affected four residents (#41, #46, #315, and #318) of five residents reviewed for arbitration agreements. The facility identified 33 residents who agreed to the facility's binding arbitration agreement upon admission. The facility census was 57. Findings include: 1. Review of the medical record for Resident #41 revealed an admission date of 10/30/24. Review of the Arbitration Agreement revealed Resident #41 and the facility entered into an agreement that if a dispute arises between them, they desire to avoid costly and time-consuming litigation. The agreement stated the agreement may be terminated by either the resident or the facility upon written notice given to the other party within 21 days of the execution of the agreement. The agreement was signed by Resident #41 and Admissions Director (AD) #899 on 11/08/24. 2. Review of the medical record for Resident #46 revealed an…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-09 · 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 observation, record review and interview the facility failed to ensure staff assisted Resident #161 out of bed. This affected one resident (#161) out of three residents reviewed for activities of daily living. The facility census was 57. Findings include: Resident #161 was admitted on [DATE] with diagnoses including cerebral infarction (stroke) with hemiplegia/hemiparesis, diabetes mellitus, intracardiac thrombosis, peripheral vascular disease, hypertensive heart disease, chronic atrial fibrillation, vitreous degeneration and aphasia (disorder that affects how you communicate. It can impact your speech, as well as the way you write and understand both spoken and written language). Resident #161's Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #161 had severely impaired cognition. Resident #161 had an impairment on one side of the upper and lower extremities, was dependent on staff for oral /personal hygiene, shower/bath, upper and lower body dressing, and rolling from left and right…

    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 · D2025-04-09 · tag F0685 — isolated
    Assist a resident in gaining access to vision and hearing services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure follow-up eye appointments were provided as indicated. This affected one (Resident #14) resident out of one reviewed for vision appointments. The facility census was 57. Findings include: Review of Resident #14 medical record revealed an admission date of 01/18/22 with diagnoses including acute kidney injury, type two diabetes mellitus, major depressive disorder, anxiety, insomnia, muscle weakness, and cervicalgia. Review of medical record revealed Resident #14 was seen by the ophthalmologist on 02/05/25. The ophthalmologist indicated Resident #14 should have a cataract evaluation with ophthalmologist of facility choice. Review of Resident #14's physical medical chart revealed an optometry order form dated 02/05/25 for referral to ophthalmologist for cataract surgery for both eyes. There was no evidence in the resident's medical chart that a referral had been sent to or scheduled as recommended. Interview on 03/31/25 09:45 A.M. with Resident #14 revealed she needed cataract surgery, and it had not been scheduled.…

    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 · D2025-04-09 · 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 observation, medical record review, staff interview, and facility policy, the facility failed to ensure pressure ulcer dressings were completed as ordered. This affected one resident (#33) of three residents reviewed for wounds. The facility census was 57. Findings include: Review of Resident #33's medical record revealed an admission date of 10/29/21. Medical diagnoses included fracture of the lower end of the left radius (arm fracture), generalized idiopathic epilepsy, aphasia (difficulty speaking), history of falls, obesity, and history of transient ischemic attacks. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #33 had a Brief Interview for Mental Status (BIMS) score of 09 which indicated moderately impaired cognition. Resident #33 was recorded to use a walker, required supervision to walk ten feet, and required moderate assistance for toileting. The assessment did not indicate Resident #33 had any behaviors or areas of skin impairment. Review of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-09 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure follow-up dental appointments were provided as indicated. This affected one resident (#6) out of one resident reviewed for dental services. The facility census was 57. Findings include: Review of Resident #6's medical record revealed an admission date of 07/12/20 with diagnosis including heart failure, morbid obesity, hemiplegia and hemiparesis following cerebral infraction affecting left non-dominate side, idiopathic neuropathy, hypertensive heart disease with heart failure, venous insufficiency, atrial fibrillation, peripheral vascular disease, primary osteoarthritis, major depressive disorder, anemia, insomnia, hyperlipidemia, tinnitus, gastro-esophageal reflux disease, and vitamin D deficiency. Review of a dental note for Resident #6 revealed she was seen by a consultant dentist on 02/11/25 for mouth pain. The dentist indicated a referral for a consult with Oral Maxillofacial Surgeon was needed. An interview on 03/31/25 at 09:58 A.M. with Resident #6 revealed she needed a follow-up dental appointment since…

    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 before2025-04-09 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, medical record review, policy review, and signage review, the facility failed to ensure enhanced barrier precautions were in place for residents as required. This affected three Residents (#33, #315, and #317) of 15 residents identified as requiring enhanced barrier precautions. The facility census was 57. Findings include: 1. Review of the medical record for Resident #315 revealed an admission date of 03/24/25 and diagnoses including metabolic encephalopathy, acute kidney failure, alcohol abuse, anxiety disorder, and atherosclerotic heart disease. Review of the physician's orders dated 03/30/25 for Resident #315 revealed an order for intravenous midline site for intravenous antibiotic administration. Review of the physician's order dated 03/31/25 for Resident #315 revealed order for enhanced barrier precautions (EBP) related to intravenous access. Observation on 03/31/25 at 10:36 A.M. revealed Resident #315 was sitting up in bed with visible intravenous access to the 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-09 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, interview, facility policy review, the facility failed to ensure residents were assessed for vaccination status and offered the influenza and/or pneumococcal vaccines. This affected three residents (#59, #315, and #317) of six residents reviewed for vaccines. The facility census was 57. Findings include: 1. Review of the medical record for Resident #59 revealed an admission date of 01/25/25 with diagnoses including left artificial joint, loose left hip artificial joint, diabetes mellitus, congestive heart failure, chronic kidney disease, rheumatoid arthritis, iron deficiency anemia, hypothyroidism, depression, anxiety, cardiac/vascular implant, and insomnia. Review of Resident #59's physical medical record revealed no influenza vaccination assessment and consent forms. Resident #59's medical record revealed no documentation or influenza vaccinations being offered for the 2024-2025 influenza season. Interview on 04/02/25 at 10:49 A.M. with Unit Manager #832 confirmed the above findings. 2. Review of the medical record for Resident #315 revealed an admission…

    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 · D2025-04-09 · tag F0887 — isolated
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, interview, and review of facility policy, the facility failed to ensure the COVID-19 vaccine was timely offered to residents. This affected three residents (#59, #315, and #317) of six residents reviewed for vaccines. The facility census was 57. Findings include: 1. Review of Resident #59's medical record revealed an admission date of 01/25/25 with diagnoses including left artificial joint, loose left hip artificial joint, diabetes mellitus, congestive heart failure, chronic kidney disease, rheumatoid arthritis, iron deficiency anemia, hypothyroidism, depression, anxiety, cardiac/vascular implant, and insomnia. A review of Resident #59's medical record revealed the facility did not offer the COVID-19 (corona virus 19) vaccine to Resident #59. The consent for the COVID-19 vaccine was unsigned, undated, and the information on the consent had not been completed. Interview on 04/02/25 at 10:49 A.M. with Unit Manager #832 confirmed the above findings. 2. Review of Resident #315's medical record revealed an admission date of 03/24/25 and diagnoses including…

    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 · D2024-11-05 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, observation, and interview, the facility failed to ensure appropriate and reasonable accommodations of needs were in place to ensure resident safety. This affected one resident (Resident #63) of four residents (#40, #61, #62, and #63) reviewed for falls. The facility census was 59. Findings include: Review of the medical record for Resident #63 revealed an admission date of 10/31/24. Diagnoses included history of falling, nondisplaced fracture of right leg, polyarthritis, and chronic obstructive pulmonary disease (COPD). Review of the admission/readmission nursing progress note dated 10/31/24 at 4:20 P.M. revealed on 10/31/24 at 2:30 P.M. Resident #63 was admitted to the facility from a short term general hospital with the diagnoses of falls and closed fracture of right tibia no surgical intervention. The resident was oriented to the room and instructed on the use of the call light. The note stated Resident #63 was alert, oriented to self, not oriented to place, not oriented to the day, not oriented to the date, and not oriented to time. The note also…

    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 before2024-01-30 · 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

    Based on medical record review, resident interview, staff interview, review of facility accident logs, and review of the facility policy, the facility failed to ensure falls were documented and investigated with follow-up interventions implemented as needed. This affected one (Resident #42) of three residents reviewed for activities of daily living (ADLs.) The facility census was 61. Findings include: Review of the medical record for Resident #42 revealed an admission date of 12/29/23 with diagnoses including spondylosis without myelopathy or radiculopathy to the lumbar region, muscle weakness, difficulty in walking, and arthrodesis. Review of the fall risk assessment for Resident #42 dated 12/29/23 revealed the resident required an assistive device for mobility and assistance with bed mobility, transfers, and ambulation. Further review of the assessment revealed Resident #42 was at a moderate risk for falls. Review of the physician orders for Resident #42 revealed an order dated 12/29/23 to keep call light within reach at all times. Review of the care plan for Resident #42 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 9 citations
  • Potential for harm · E2023-10-05 · tag F0583 — failed to protect personal privacy — pattern
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview the facility failed to maintain confidentiality of resident medical information and provide privacy during the delivery of wound care. This affected one resident (Resident #38) and had the potential to affect 20 residents who resided on the long term care hallway. The facility census was 48. Findings include: Tour of the long term care hallway on 10/02/23 at 9:28 A.M. revealed a desk top computer monitor at the nurse station was visible from the public hallway and left open to a resident electronic medical Record (EMR). The nurses station and monitor was unattended by staff. Interview on 10/02/23 at 9:32 A.M. with Licensed Practical Nurse (LPN) #849 verified the computer was visible from the public hallway and identifying resident information was open and visible. LPN #849 stated she forgot to close out the medical record prior to leaving the area. Observation of Resident #38's wound care on 10/03/23 at 3:08 P.M. with LPN #849 and State Tested Nurse Assistant (STNA) #920 revealed LPN #849 completed wound care to Resident #38's right ankle wound…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-05 · tag F0569 — isolated
    Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
    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 close a resident fund account and convey funds in a timely manner after discharge. This affected one (#71) of five residents (#20, #42, #44, #71, and #72) whose resident fund accounts were reviewed. The facility census was 48. Findings include: Review of the medical record for Resident #71 revealed an admission date of 12/23/21 and a discharge date of 08/22/22. Review of Resident #71's resident fund account quarterly statement for September 2022 revealed on 09/23/22 close trust account with $1,287.03 debited. Review of facility check number 1035 dated 09/23/22 revealed a sum of $1,287.03 to be paid to Resident #71. Review of Resident #71's resident fund account for October 2022 revealed a deposit for $1,145.00 from social security and a closing balance of $1,145.02 due to interest. Review of Resident #71's resident fund account for November 2022 revealed a deposit of $1,145.00 from social security and a closing balance of $2,290.05 due to interest. Review of the facility check number 1053 dated 12/05/22 revealed a sue…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-05 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review the facility failed to obtain weekly weights per physician orders and ensure the physician was notified of weight changes. This affected one (#52) of two residents reviewed for nutrition (#52 and #53). The facility census was 48. Findings include: Review of the medical record for Resident #52 revealed an admission date of 09/06/23. Diagnoses included left femur fracture, repeated falls, Raynaud's disease, history of breast cancer, and feeding tube. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #52 had intact cognition, required extensive assistance for bed mobility and transfers. The MDS assessment also indicated Resident #52 required total dependence of one staff for eating, weight was 121 pounds, and Resident #52 received 51% or more of calories and 501 milliliters (ml) per day or more from feeding tube. Review of the physician orders for September 2023 revealed an order to monitor weight weekly for four weeks every…

    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 before2023-10-05 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, and policy review, the facility failed to ensure oxygen tubing was up-to-date and sterile water containers were changed and dated for use with oxygen concentrator. This affected one resident (#8) of one resident reviewed for oxygen. The facility identified four Residents (#1, #8 #33, #35) who utilized oxygen. The facility census was 48. Findings include: Review of the medical record for Resident #8 revealed an admission date of 07/18/23 with diagnoses that included metabolic encephalopathy, anemia, pleural effusion, and chronic obstructive pulmonary disease (COPD). Review of the 5-Day, Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 13 that indicated she was alert and oriented to person, place, and time. Review of the MDS assessment revealed Resident #8 was a one-person physical extensive assistance for activities of daily living (ADLs). Review of the care plan dated 09/28/23…

    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 · Fcited before2021-07-13 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview the facility failed to ensure proper infection control practices were maintained for residents in isolation. This affected one resident (Resident #39)of one resident reviewed for transmission based precautions. The facility census was 60. Findings include: Review of the medical record revealed Resident #39 was admitted to the facility on [DATE] with diagnoses including rectal cancer, liver cancer, and anxiety disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had mild cognitive impairment and required two staff assistance for activities of daily living. Interview with the Director of Nursing on 07/08/21 at 10:55 A.M. revealed Resident #39 was residing on the facilities New admission Monitoring Unit and was on isolation precautions for 30 days per facility policy due to Resident #39 not being vaccinated against COVID-19. Observation of the sign outside of Resident #39's room on 07/08/21 at 10:57 A.M. revealed a sign…

    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 · D2021-07-13 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to ensure a pre-admission screen and resident review (PASRR) was completed as required for Resident #360. This affected one (Resident #360) of two residents reviewed for PASRR. The facility census was 60. Findings include: Review of the medical record revealed Resident #360 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, chronic kidney disease, and dementia. Review of the census records for Resident #360 revealed Resident #360 was admitted to the facility from a hospital. Prior to Resident #360's hospital stay, he was admitted to another skilled nursing facility on 05/07/21. Review of the admission paperwork for Resident #360 revealed he was admitted to his previous facility on a hospital exemption which required completion of the PASRR form 3622 within 30 days of admission. No PASRR form was completed by the previous facility. Since Resident #360's had not discharged to the community from his previous…

    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 · D2021-07-13 · 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, interview and policy review, the facility failed to ensure Resident #364's call light was answered in a timely manner. This affected one of one resident reviewed for call light response time. The facility census was 60. Findings include: Review of the medical record reviewed Resident #364 was admitted to the facility on [DATE] with diagnoses including fibromyalgia, type two diabetes, and major depressive disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment revealed Resident #364 required extensive assistance for toileting and was incontinent of her bowels. Observation of Resident #364's room on 07/08/21 at 1:33 P.M. revealed Resident #364's call light was turned on. Observation of the hallway of Resident #364's room on 07/08/21 at 1:37 P.M. revealed Maintenance Director #127 was within visual eye sight (about 30 feet) of Resident #364's call light and did not answer the call light. Observation of the hallway of Resident #364's room on 07/08/21 at 1:41…

    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 before2021-07-13 · 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 interview, record review and policy review, the facility failed to obtain Resident #48's weight daily per physician's order. This affected one (Resident #48) of three residents (Resident's #48, #37, and #256) reviewed for nutrition. The facility census was 60. Findings include: Review of the medical record for Resident #48 revealed an admission date of 12/21/20 with diagnoses including cerebral infarction, congestive heart failure, atrial fibrillation, and hypothyroidism. Review of the Medication Administration Record (MAR) and weight record for June 2021 revealed there was no documented evidence Resident #48's daily weight was completed on 06/11/21, 06/12/21, 06/13/21, 06/18/21, 06/23/21, 06/28/21, 06/29/21, and 06/30/21. The MAR revealed Resident #48 was sleeping, and there was no documented evidence of further attempts to obtain her weight on 06/10/21, 06/17/21, 06/24/21, and 06/26/21. Review of the care plan last revised 06/02/21 revealed Resident #48 was at risk for altered nutrition and hydration…

    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 before2021-07-13 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, record review and policy review, the facility failed to ensure Resident #35's respiratory equipment was dated and/or documented when it was changed last. This affected one (Resident #35) of one resident reviewed for respiratory care. This had the potential to affect 12 residents (Resident's #358, #361, #157, #23, #43, #158, #159, #33, #39, #359, #35 and #360) with respiratory equipment. The facility census was 60. Findings include: Review of the medical record for Resident #35 revealed an admission date of 12/23/20 with diagnoses including congestive heart failure, chronic obstructive pulmonary disease, obstructive sleep apnea, and morbid obesity. Review of the care plan dated 04/12/21 revealed Resident #35 had an ineffective breathing pattern as evidenced by shortness of breath, chronic obstructive pulmonary disorder, and congestive heart failure. Interventions included adjust head of bed and body positioning to assist with ease of respirations, administer oxygen per physician…

    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

“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 O'NEILL HEALTHCARE — 6 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 54.2-0.2 vs chain
Health inspection 3 of 53.7-0.7 vs chain
Staffing 2 of 52.0≈ chain avg
Quality measures 5 of 54.8+0.2 vs chain
The other 5 homes this chain runs (chain average 4.2★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
CARLOW LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 01/01/2012
ONEILL, DEBORAHIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER11%since 01/01/2012
ONEILL, JOHNIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER30%since 01/01/2012
ZISKA, DOREENIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST19%since 01/01/2012
WILLIAMS, KARENIndividualCONTRACTED MANAGING EMPLOYEEsince 01/02/2019
O'NEILL MANAGEMENT, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 11/15/2001

CMS files one row per role, so the 8 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.

2 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.

$11.0M
Net patient revenuemost recent cost report
-14.7%
Operating marginrevenue minus expenses
$3.1M
Related-party expense24% of expenses
Who pays — share of resident-days
Medicaid 5%Medicare 6%Other / private 89%

This home reported $3.1M 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

$297per resident / day
operating cost
$9,033per month
≈ monthly operating cost
$259per 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 366272. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-09, 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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