Norwalk Memorial Home
272 Benedict Ave, Norwalk, OH 44857 · Non profit - Corporation · 69 certified beds · (419) 668-8101 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0606), cited Aug 2024
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 2 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 held steady at 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 19.0% | 5.3% | 15.4% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 11.7% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.6% | 0.2% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.2% | 0.4% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 4.3% | 30.1% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.6% | 3.2% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 16.2% | 6.1% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 28.3% | 25.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 95.7% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.8% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 25.1% | 21.4% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 14.9% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 70.7% | 75.6% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 30.1% | 24.9% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 12.0% | 12.9% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 0.72 | 1.73 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.67 | 1.80 | 1.80 | 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.
63.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 231 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 25.6% 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 129 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 0.33 therapist hours per resident per day in 2026Q1 — more than 54% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 5% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 63.5%CMS range 57.9–69.1 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.6%CMS range 9.6–16.7 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 25.6% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 32.6% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 20.2% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 99.4% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | 98.2% | 100.0% | Oct 2024–Sep 2025 | CMS 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 discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 stay | 1.9% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 4.3% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.7%CMS range 3.7–11.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.80 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 69 beds and averages 59.0 residents a day — about 86% 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 3.72 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.69 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.98 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 3.54 hrs/resident/day on weekends vs 3.79 on weekdays — 7% thinner on weekends. RN hours go from 0.81 to 0.37 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 41% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.
- Potential for harm · E2025-12-30 · tag F0729 — patternVerify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
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 personnel file review, online State of Ohio State Tested Nursing Aide Registry review, staff interview and review of facility policy, the facility failed to ensure a current/active license for one, Certified Nursing Assistant #117, of five employees reviewed for current/active licensure. This had the potential to affect all residents. The facility census was 54. Review of Certified Nursing Assistant (CNA) #117's personnel file revealed a hire date of [DATE].Review of the Ohio Department of Health State Tested Nursing Aide registry review dated [DATE] at 2:58 P.M. revealed CNA #117's registry had expired on [DATE] and she was not eligible to work.Review of the facility staffing schedule revealed CNA #117 worked in the capacity of a state tested nursing assistant on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE],…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-08-15 · tag F0758 — failed to limit and justify psychotropic drugs — patternImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, review of the Food and Drug Administration (FDA) Black Box Warning information, and policy review, the facility failed to ensure psychotropic medications were administered to address appropriate conditions that reflect resident current health conditions and failed to ensure the residents were adequately monitored while receiving psychotropic medications. This affected four (#17, #46, #47, and #51) of five residents reviewed for unnecessary medications. The facility census was 66. Findings include: 1. Review of the medical record revealed Resident #17 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, dementia in other diseases classified elsewhere elsewhere with psychotic disturbance, and anxiety disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident # 17 was severely cognitively impaired and required extensive assistance of one staff person for completing her activities 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.
- Potential for harm · Dcited before2024-08-15 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
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 room and board rates, and staff interview, the facility failed to ensure Skilled Nursing Facility Advanced Beneficiary Notices (SNF ABNs) contained all required and accurate information. This affected two (#51 and #112) of three residents reviewed for beneficiary notices. The facility census was 66. Findings Include: 1. Review of the medical record revealed Resident #51 was admitted to the facility on [DATE] with diagnoses including dementia, disorientation, and skin cancer. Review of the SNF ABN provided to Resident #51 on 12/26/23, prior to the discontinuation of skilled services on 12/29/23, revealed the notice contained no information regarding what skilled services were being discontinued and noted the estimated cost per day of the service as $235.00 per day. Review of the facility's current room and board rates revealed a semi-private room had a cost of $240.00 which included no skilled services. The SNF ABN provided to Resident #51 had no cost estimate for the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-15 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of resident census information, email correspondence with the local Ombudsman, and staff interview, the facility failed to ensure the state Ombudsman's office was notified of resident discharge or transfer from the facility as required. This affected two (#30 and #60) of two residents reviewed for hospitalization. The facility census was 66. Findings include 1. Review of the medical record revealed Resident #30 was admitted to the facility with an initial admission date of 03/15/18 and re-admission date of 01/17/19. Diagnoses included Parkinson's disorder, dementia with mood disturbance and anxiety, and type II diabetes mellitus. Review of nursing progress notes and resident census records revealed Resident #30 was transported to a local hospital on [DATE], 01/08/24, and 02/20/24. Review of both the electronic and paper medical records revealed no evidence the state Ombudsman was notified of Resident #30's transfers to the hospital. 2. Review of the medical record revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-15 · tag F0740 — failed to provide behavioral / mental-health care — isolatedEnsure each resident must receive and the facility must provide necessary behavioral health care and services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, medical record review, and review of hospital provider documentation, the facility failed to timely implement behavioral health services upon return from an emergency department (ED) visit for suicidal ideations. This affected one (#46) of three residents reviewed for behaviors. The facility census was 66. Findings include: Review of the medical record for Resident #46 revealed an admission date of 07/03/24. Medical diagnoses included left femur fracture, depression, and anxiety. Review of Resident #46's Minimum Data Set (MDS) 3.0 admission assessment, dated 07/10/24, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. Resident #46 was not recorded to have any hallucinations, delusions, behaviors or rejection of care. Review of Resident #46's physicians orders, dated 07/05/24, revealed the resident had orders for buspirone (an anti-anxiety medication) 15 milligrams (mg) three times daily routine, duloxetine (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.
- Potential for harm · D2024-08-15 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, medical record review, review of manufacturer guidelines, and policy review, the facility failed to ensure residents were free from significant medication administration errors. This affected one (#04) of four residents observed for medication administration. The facility census was 66. Findings include: Review of the medical record for Resident #04 revealed an admission date of 07/04/18. Medical diagnoses included type II diabetes mellitus with diabetic chronic kidney disease and dementia. Review of Resident #04's Minimum Data Set (MDS) 3.0 annual assessment, dated 07/06/24, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 06 indicating severely impaired cognition. The resident was recorded to have received insulin injections daily over the seven-day assessment look back period. Review of Resident #04's care plan, revised on 08/21/23, revealed the resident had a diagnosis of diabetes mellitus and had listed interventions which included to administer medications as ordered by the doctor. Review of Resident #04's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-03-21 · tag F0550 — failed to protect resident dignity and rights — patternHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and staff interview, the facility failed to serve residents seated together for meals at the same time. This affected nine (#20, #40, #44, #5, #19, #23, #15, #26, and #13) of twelve residents observed in the dining room during lunch service. The facility census was 61. Findings include: Observation on 03/15/22 from 11:30 A.M. to 11:55 A.M. of the dining room revealed five dining tables and four staff serving resident lunch meals. Observation on 03/15/22 at 11:30 A.M. of Table Two revealed Resident #28 sitting at the table with her meal. Resident #40, also sitting at Table Two, was not served his lunch meal until 11:43 A.M. Resident #44 was also sitting at Table Two and was not served the lunch meal until 11:45 A.M. Observation on 03/15/22 at 11:33 A.M. of Table One revealed Resident #5 sitting at the table with her lunch meal. Resident #19, sitting at the same table, was not served his lunch meal until 11:42 A.M. Observation on 03/15/22 at 11:33 A.M. of Table Three revealed Resident #23 was served his lunch meal. Resident #15, Resident #13, and Resident #26 were…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-03-21 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, and review of a facility policy, the facility failed to complete shiftily reconciliation counts for controlled medications stored in medication carts and refrigerators on the Transitional Care Unit (TCU). This deficient practice affected nine (#1, #2, #32, #53, #54, #55, #56, #57, and #153) residents with controlled substances kept in the medication cart or refrigerator in the TCU. The census was 61. Findings include: Observation of the medication cart and refrigerator in the TCU on 03/15/22 at 1:44 P.M. with Licensed Practical Nurse (LPN) #225 and Registered Nurse (RN) #306 revealed 13 total controlled medications were stored in the medication cart and refrigerator. Resident #1, Resident #2, Resident #53, Resident #54, Resident #55, Resident #56, Resident #57, and Resident #153's medications were in pill form and stored in the medication cart and Resident #32's medication was in liquid form and stored in the refrigerator. A controlled substance reconciliation was completed with LPN #225 and RN #306 and all counts verified as correct with all…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-03-21 · tag F0761 — failed to label and store drugs safely — patternEnsure 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, staff interview, and review of a facility policy, the facility failed to ensure medications were stored securely in the medication cart during medication administration. This had the potential to affect 23 Residents (#3, #4, #6, #11, #15, #16, #17, #18, #20, #21, #23, #26, #27, #31, #32, #33, #34, #35, #40, #41, #44, #49 and #303) residing on the B Hall and left side of C Hall for whom the medications were administered by the facility. The facility census was 61. Findings include: Observation on 03/15/21 at 7:47 A.M. of medication administration was observed for Resident #4. Upon the gathering of this resident's medications, Licensed Practical Nurse (LPN) #204 walked away from the unlocked medication cart at 8:03 A.M. and entered Resident #4's bedroom. At 8:06 A.M. LPN #204 returned to medication cart to obtain a spoon for Resident #4, at which time LPN #204 locked the medication cart. At the time of the observation LPN #204 verified the unlocked medication cart was unattended and out of her sight for three minutes. Interview on 03/17/21 at 8:06 A.M., LPN #204…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-03-21 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, review of the Centers for Disease Control and Prevention (CDC) guidelines, and review of facility policy, the facility failed to ensure staff were wearing the appropriate personal protective equipment (PPE) when entering the room of a resident on quarantine for unknown COVID-19 status, changed PPE when exiting the quarantine room, and unvaccinated staff were wering a N95 when entering resident rooms. This had the potential to affect 13 residents (#2, #25, #45, #48, #53, #54, #55, #56, #58, #59, #153, #154, and #304) The facility census was 61. Findings include: Medical record review revealed Resident #153 had an admission date of 03/08/22. Diagnoses included type two diabetes mellitus, hypertension, dementia, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Review of physician orders dated 03/08/22 revealed Resident #153 was placed on droplet precautions until 03/22/22 due to not being vaccinated for COVID-19. Review of a nurse progress note dated 03/08/22 at 10:30 P.M. revealed droplet precautions…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 13 citations
- Potential for harm · Dcited before2022-03-21 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of a facility policy, the facility failed to ensure advance directives were consistent throughout the medical record for one (#9) of 24 residents reviewed for advance directives. The census was 61. Findings include: Review of Resident #9's medical record revealed an initial admission date of [DATE] and a most recent admission date of [DATE]. Diagnoses included diabetes mellitus type II, chronic kidney disease, chronic obstructive pulmonary disease, muscle weakness, and hypertension. Review of the admission Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #9 was assessed with moderately impaired cognition. Review of the most recently completed MDS assessment, dated [DATE], revealed Resident #9 had intact cognition. Review of Resident #9's physical chart revealed an advanced directives designation for Resident #9 to be Do Not Resuscitate Comfort Care (DNRCC)-Arrest, which meant providers would treat Resident #9 as any other resident with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-03-21 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, review of the Beneficiary Protection Notification Review, and staff interview, the facility failed to provide the Advance Beneficiary Notice of Non-Coverage when Medicare Part A services ended to one (#41) of three residents reviewed for Beneficiary Protection Notification. The facility census was 61. Findings include: Review of the Beneficiary Protection Notification Review, completed 03/16/22, revealed Resident #41's last covered day of Medicare Part A Skilled Services was 03/06/22. The Notice of Medicare Non-Coverage was provided on 03/04/22. There was no evidence the Advance Beneficiary Notice (ABN) of Non-Coverage was provided to Resident #41 or his representative. Interview on 03/16/22 at 11:03 A.M., the Administrator revealed Resident #41 remained in the facility after Medicare Part A services ended. The Administrator verified the ABN should have been provided to Resident #41 and the resident's representative, but was not. The Administrator stated the ABN was explained to Resident #41, but the Social Worker forgot to provide the document to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-03-21 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure 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 medical record review, observation, staff interview, and review of facility policy, the facility failed to assess the use of a pressure mat alarm used as a fall precaution to prevent a resident from changing positions without staff assistance. This affected one (#31) of one resident reviewed for pressure mat alarms. The facility identified 17 residents who utilized pressure mat alarms for fall precautions. The facility census was 61. Findings include: Review of the medical record revealed Resident #31 was admitted on [DATE]. Diagnoses included Parkinson's disease, Alzheimer's disease, major depressive disorder, anxiety disorder, hypertension, heart disease, and transient cerebral ischemic attack. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/03/22, revealed Resident #31 was severely cognitively impaired, required extensive assistance with bed mobility and transfers, and had no falls since the previous assessment. Resident #31 used a bed alarm daily. Review of the plan of care,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-03-21 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of facility policy, the facility failed to provide written notice of transfer for hospitalizations. This affected two (#47 and #33) of two residents reviewed for transfer notification. The facility census was 61. Findings include: 1. Review of the medical record revealed Resident #47 was admitted on [DATE] and discharged on 03/04/22. Diagnoses included type II diabetes, hypertension, anxiety disorder, major depressive disorder, hemiplegia and hemiparesis, morbid obesity, and dysphagia following unspecified cerebrovascular disease. Review of the admission Minimum Data Set (MDS) assessment, dated 03/01/22, revealed Resident #47 was severely cognitively impaired. Review of a nursing progress note dated 03/04/22 revealed Resident #47 was discharged and sent to the emergency department for stroke like symptoms. Review of a nursing progress note dated 03/04/22 revealed Resident #47 was admitted to the hospital and would not be returning to the facility that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-03-21 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of facility policy, the facility failed to provide bed hold notification to residents transferred to the hospital. This affected two (#47 and #33) of two residents reviewed for bed hold notification. The facility census was 61. Findings include: 1. Review of the medical record revealed Resident #47 was admitted on [DATE] and discharged on 03/04/22. Diagnoses included type II diabetes, hypertension, anxiety disorder, major depressive disorder, hemiplegia and hemiparesis, morbid obesity, and dysphagia following unspecified cerebrovascular disease. Review of the admission Minimum Data Set (MDS) assessment, dated 03/01/22, revealed Resident #47 was severely cognitively impaired. Review of a nursing progress note dated 03/04/22 revealed Resident #47 was discharged and sent to the emergency department for stroke like symptoms. Review of a nursing progress note dated 03/04/22 revealed Resident #47 was admitted to the hospital and would not be returning to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-03-21 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of medical record, family interview, and staff interview, the facility failed to ensure a resident and resident family were provided a written summary of the baseline care plan. This affected one (#154) of one resident reviewed for baseline care plans. The facility census was 61. Findings include Medical record review revealed Resident #154 had an admission date of 03/07/22. Diagnoses included pneumonia, type two diabetes mellitus, Parkinson's disease, chronic kidney disease, and dementia. Interview on 03/14/22 at 2:12 P.M., with Resident #154's family member revealed the resident had not had an initial care plan meeting. Resident #154's family member also revealed the resident had not been provided with a written summary of the baseline care plan. Interview on 03/16/22 at 10:39 A.M., Registered Nurse (RN) #306 was unaware if residents and their families received a copy of the baseline plan of care. RN #306 stated her orientation on paperwork was not in depth. Interview on 03/16/22 at 10:50 A.M. with RN #300 revealed residents or their families would sign the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-05-30 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of a facility policy, the facility failed to ensure resident's advanced directive wishes were consistent throughout the medical record. This affected two (#47 and #46) of 24 residents reviewed for advanced directives. The facility census was 69. Findings include: 1. Medical record review revealed Resident #47 admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, hypertension, and major depressive disorder. Review of the quarterly Minimum Data Sets (MDS) assessment dated [DATE], revealed the resident was cognitively intact. Review of Resident #47's physician orders, dated [DATE], revealed the resident's advanced directive wish was Full Code which meant resuscitative actions (including the use of powerful heart or blood pressure medications and/or cardiopulmonary resuscitation (CPR) to maintain life) were to be attempted if the resident went into cardio and/or pulmonary arrest. Review of the resident's computer…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-05-30 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, review of Self-Reported Incident (SRI) investigation, staff interview, and review of facility policy, the facility failed to follow their policy to timely report an injury of unknown origin to the Administrator and the State Agency for one (#3) of one resident reviewed for an injury of unknown origin. This had the potential to affect all 69 residents of the facility. Findings include: Review of the medical record revealed Resident #3 was admitted to the facility 01/24/13. Diagnoses included anxiety, depression, stroke, hemiplegia, dementia and osteopenia. Review of the Minimum Data Set (MDS) assessment, dated 05/01/19, for Resident #3 revealed the resident was assessed with moderate cognitive impairment. The resident required total dependence and two-person physical assist for transfers. Review of the care plan updated 04/19/19 for Resident #3 revealed the resident was planned as non-ambulatory with total dependence for transfers with the use of a mechanical lift. Review of the nursing note dated 05/04/19 at 3:15 A.M. for Resident #3 revealed the nurse was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-05-30 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, review of Self-Reported Incident (SRI) investigation, staff interview, and review of facility policy, the facility failed to timely report an injury of unknown origin to the Administrator and the State Agency for one (#3) of one resident reviewed for an injury of unknown origin. This had the potential to affect all 69 residents of the facility. Findings include: Review of the medical record revealed Resident #3 was admitted to the facility 01/24/13. Diagnoses included anxiety, depression, stroke, hemiplegia, dementia and osteopenia. Review of the Minimum Data Set (MDS) assessment, dated 05/01/19, for Resident #3 revealed the resident was assessed with moderate cognitive impairment. The resident required total dependence and two-person physical assist for transfers. Review of the care plan updated 04/19/19 for Resident #3 revealed the resident was planned as non-ambulatory with total dependence for transfers with the use of a mechanical lift. Review of the nursing note dated 05/04/19 at 3:15 A.M. for Resident #3 revealed the nurse was made aware of a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-05-30 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of facility policy, and staff interview, the facility failed to provide written notification of a transfer to the hospital for one (#67) of two residents reviewed for hospitalization. The facility census was 69. Findings include: Medical record review revealed Resident #67 admitted to the facility on [DATE]. Diagnoses included a left hip fracture, Diabetes mellitus, and hypertension. Further review revealed the resident was transferred to an acute care hospital on [DATE]. There was no documentation the facility provided the resident and the residents representative written notification of the reason for the transfers. Interview on 05/30/19 at 8:47 A.M., the Director of Nursing (DON) revealed the resident's nurse was responsible for filling out a transfer form indicating the reason for the resident's need for a transfer to an acute care hospital. The nurse was supposed to give a copy of the form to the resident and the resident's family, if they were present. If the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-05-30 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to have a policy regarding resident bed holds upon transfer from the facility and failed to provide notification of the facility bed hold policy upon discharge to an acute care hospital for two (#67 and #65) of two residents reviewed reviewed for hospitalization. The facility identified 12 residents identified by the facility who discharged to the hospital. The facility census was 69. Findings include: 1. Medical record review revealed Resident #67 admitted to the facility on [DATE]. Diagnoses included a left hip fracture, Diabetes mellitus, and hypertension. The resident was transferred and admitted to an acute care hospital on [DATE]. No documentation the facility notified the resident of the facility's bed hold policy was found in the resident's medical record. 2. Medical record review revealed Resident #65 admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, chronic obstructive pulmonary disease, and major…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2024-08-15 · tag F0606 — failed to not employ staff found guilty of abuse — widespreadNot hire anyone with a finding of abuse, neglect, exploitation, or theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of personnel files, staff interview, and review of the facility abuse policy, the facility failed to develop and implement policies and procedures to include screening of all employees against the State of Ohio Nurse Aide Registry to identify if an employee had a finding concerning abuse. This had the potential to affected all 66 residents residing in the facility. The census was 66. Findings Include: Review of the personnel files for the Director of Nursing (DON), Licensed Practical Nurse (LPN) #249, LPN #273, and Dietary Aide (DA) #280 revealed no evidence they were screened prior to employment using the State of Ohio Nurse Aide Registry. The identification of findings would be necessary to determine if any employee had actions identified that would validate allegations of abuse, neglect, exploitation, mistreatment of residents, or misappropriation of their property. Interview with Human Resource Director (HRD) #300 on 08/15/24 at 9:00 A.M. verified there was no evidence that the DON, LPN #249, LPN #273, and DA #280 were screened using the State of Ohio Nurse Aide…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2024-08-15 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, and policy review, the facility failed to ensure posted nursing staff information was posted daily as required. This had the potential to affect all 66 residents. The facility census was 66. Findings include: Upon entrance to the facility for an annual survey on 08/12/24 at 8:05 A.M., observation of the posted nursing staffing information for staff directly responsible for resident care was noted to be dated 08/09/24. On 08/12/24 at 8:08 AM, interview with Licensed Practical Nurse (LPN) #263 verified the posted nursing staffing information for staff directly responsible for resident care was dated 08/09/24 and was not up to date. Review of the policy titled, Nursing-Posting Direct Care Daily Staffing Numbers, dated 08/01/24, revealed within two (2) hours of the beginning of each shift, the number of Licensed Nurses (Registered Nurses and LPNs) and the number of unlicensed nursing personnel (state tested nurse aides) directly responsible for residents care will be posted in a prominent location (accessible to residents and visitors) and in a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| FISHER TITUS HEALTH | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 07/01/2016 |
| BURKEY, BRENT | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/05/2018 |
| CAMP, DENNIS | Individual | CORPORATE DIRECTOR | — | since 07/01/2017 |
| CORIELL, MARK | Individual | CORPORATE DIRECTOR | — | since 07/01/2017 |
| DOUGHTY, DENNIS | Individual | CORPORATE DIRECTOR | — | since 07/01/2015 |
| HAZEL, SUSAN | Individual | CORPORATE DIRECTOR | — | since 07/01/2017 |
| HUBER, JEFFERY | Individual | CORPORATE DIRECTOR | — | since 07/01/2018 |
| HUGHES, JOHN | Individual | CORPORATE DIRECTOR | — | since 05/01/2020 |
| LENDRUM, JOHN | Individual | CORPORATE DIRECTOR | — | since 05/01/2020 |
| ROBERTS, JULIE | Individual | CORPORATE DIRECTOR | — | since 07/01/2018 |
| ZAHLER, JONATHAN | Individual | CORPORATE DIRECTOR | — | since 07/01/2017 |
| MATTNER, MATTHEW | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 03/12/2024 |
| SILVESTRI, SCOTT | Individual | CORPORATE OFFICER | — | since 11/18/2025 |
CMS files one row per role, so the 16 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
What families pay in OH
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Ohio Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 365668. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-08-15, 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.