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Welcome Nursing Home

417 South Main Street, Oberlin, OH 44074 · For profit - Corporation · 99 certified beds · (440) 775-1491 Medicare & Medicaid certified

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Flagged for abuse
Insights

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

In its favor
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (28% vs 45% nationally) — better care continuity
Worth asking about
  • CMS has flagged it for abuse
  • it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Mar 2026
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — 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 (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (2/5)

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

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

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

Worth a closer look. This home's staffing and quality-measure ratings run 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, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
5 S Main St · (440) 774-7300 · Call to confirm hours
Pharmacy
297 S Main St · (440) 774-3531 · Call to confirm hours
Grocery
65 E College St · (440) 774-4962 · Call to confirm hours
Park
Oberlin Trl · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 4 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 4 to 2 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 rating2★
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 increased9.7%5.3%15.4%worse than state — see note marked double-dagger below the table
Long-stay residents who lose too much weight5.0%6.2%5.4%typical
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 infection0.9%0.4%2.0%worse than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms5.6%30.1%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.1%3.2%3.3%better
Long-stay residents whose ability to walk worsened14.6%6.1%16.1%typical
Long-stay residents on antianxiety or hypnotic medication9.6%25.5%18.9%better
Long-stay residents given the seasonal flu vaccine98.8%94.5%95.3%typical
Long-stay residents with pressure ulcers3.7%3.4%4.7%better
Long-stay residents with worsening bladder/bowel control26.6%21.4%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table12.6%8.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine84.2%75.6%79.4%typical
Short-stay residents rehospitalized after admission25.4%24.9%22.6%worse
Short-stay residents with an outpatient ER visit5.4%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.

38.4% 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 45 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

38.4%U.S. median 51.5%
Got home and stayed home
11.5%U.S. median 10.7%
Went back to hospital
44.4%U.S. median 56.6%
Met the expected recovery
0.20U.S. median 0.31
Therapy hours / resident / day
0.07hours / resident / day
Physical therapy
0.08hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 44.4% 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 27 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 0.20 therapist hours per resident per day in 2026Q1 — more than 23% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 16% 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 SNF38.4%CMS range 27.0–50.951.5%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 8.1–16.410.7%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 discharge44.4%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 discharge29.6%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 discharge44.4%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay6.2%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 worsened0.0%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 hospitalization7.0%CMS range 3.5–11.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.071.02Oct 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

0.61
RN hours/ resident / day
1.01
LPN hours/ resident / day
2.47
Aide hours/ resident / day
4.09
Total nurse hours/ resident / day
0.26
RN hoursweekends
27.7%
Total nursing turnover
14.3%
RN turnover

How full it usually is: this home is certified for 99 beds and averages 90.4 residents a day — about 91% occupied, or roughly 9 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.09 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.61 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.47 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.56 hrs/resident/day on weekends vs 4.30 on weekdays — 17% thinner on weekends. RN hours go from 0.75 to 0.26 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 28% is below the national median of 45%.

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

Inspection trend

15
deficiencies at the latest standard inspection (2026-03-05)
2
at the previous standard inspection (2022-10-27)

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.

22 citations, most serious first. The 10 most serious are shown; the remaining 12 are one tap away and print in full.

  • Potential for harm · F2026-03-05 · tag F0761 — failed to label and store drugs safely — widespread
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, review of the pharmacy refrigerated medication list, review of manufacturer guidelines, and review of facility policy, the facility failed to ensure safe medication handling and proper labeling of multi-use vials. Additionally, the facility failed to ensure medications were not left unattended, affecting one (#71) resident with the potential to affect the direct safety risk of 14 residents (#09, #10, #15, #16, #25, #28, #29, #39, #41, #70, #77, #81, #89, #91) who were identified by the facility as being cognitively impaired, independently ambulatory, and residing on the 200 hall. The facility census was 91. Findings include: 1.Observation on 03/03/26 at 7:30 A.M. of the medication storage room located behind the east nursing station revealed a 1 milliliter (mL) vial of Tubersol PPD (Mantoux) 10 multi-use vial, lot number 4CA12C1, with a manufacturer expiration date of 02/2028, was opened and not labeled with the date it was first used. Interview on…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-03-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    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 observation, staff interview, product label review, and facility policy review, the facility failed to ensure the resident environment was free from improperly stored hazardous chemicals. This had the potential to affect 14 residents (#9, #10, #15, #16, #25, #28, #29, #39, #41, #70, #71, #81, #89, and #91) identified by the facility as cognitively impaired and independently mobile. The facility census was 91. Findings include: Observation on 03/02/26 at 2:29 P.M. revealed a 10.1-ounce tube of 3M Fire Barrier Sealant Caulk in a caulk gun, approximately three-quarters used, sitting on a handrail in the common area of hall 200. The chemical was within reach of residents and in an area where residents frequently mobilize. Review of the product label for 3M Fire Barrier Sealant Caulk indicated: May irritate eyes, nose, and throat. Avoid eye contact. Do not swallow. Wash thoroughly after handling. Keep out of reach of children. Interview on 03/02/26 at 2:30 P.M. with Licensed Practical Nurse (LPN) #375 verified the chemical caulk tube was unsecured on the handrail in the 200 hall…

    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 · D2026-03-05 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor 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 facility policy review, the facility failed to ensure an advance directive was in the medical record for Resident #80 and further failed to ensure the advance directive forms for Residents #28 and #97 were signed by the physician. This affected three (#28, #80, and #97) of 91 residents reviewed for advance directive. The facility census was 91.Findings include:1. Review of the medical record for Resident #28 revealed an admission date of [DATE]. Diagnoses included unspecified dementia, unspecified atrial fibrillation, and sleep apnea.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 had impaired cognition. Further review of the MDS revealed Resident #28 required supervision for bathing and was independent for toileting.Review of the care plan dated [DATE] revealed Resident #28 had chosen to be a Do Not Resuscitate Comfort Care - Arrest (DNRCC - A). Interventions included for the advance directive to be in the medical…

    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 · D2026-03-05 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to ensure physician notification when a significant change in condition occurred for one resident (#66) when a lumen of the resident's peripherally inserted central catheter (PICC) line (a central venous catheter that provides access to the large veins near the heart through a peripheral vein in the arm) was occluded, preventing administration of a physician-ordered intravenous antibiotic (Meropenem). This affected one (#66) of three residents (#14, #53, and #66) receiving intravenous therapy. The facility census was 91. Findings include: Review of the medical record for Resident #66 revealed an admission date of 08/18/25 with diagnoses including chronic osteomyelitis of the ankle and foot, pressure ulcer of the left heel, type 2 diabetes mellitus, congestive heart failure, atrial fibrillation, peripheral vascular disease, chronic obstructive pulmonary disease, obesity, generalized muscle weakness, and dependence on a wheelchair. Review of Resident #66's most recent…

    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 · D2026-03-05 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure a homelike environment. This affected three (#52, #64 and #66) of three residents reviewed for a homelike environment. The facility census was 91.Findings include:Review of the medical record for Resident #64 revealed an admission date of 12/12/25 with diagnoses including bilateral osteoarthritis of the knees, weakness, generalized muscle weakness, abnormalities of gait and mobility, cognitive communication deficit, pneumonia, hypertension, pain in the right and left knee, shortness of breath, hyperlipidemia, hypothyroidism, personal history of malignant neoplasm of the thyroid, lymphedema, neuralgia and neuritis, alcohol dependence, and stage three chronic kidney disease (CKD3).Review of Resident #64's Medicare 5-Day Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively…

    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 · D2026-03-05 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, review of a facility self-reported incident, and review of facility policy the facility failed to protect residents from abuse. This affected two (#100 and #41) of two residents reviewed for abuse with the ability to affect all residents. The facility census was 91.Findings include: 1.Review of Former Resident (FR) #100's medical record revealed an admission date of 03/20/21 and a discharge date of 09/04/25. Diagnoses included osteoarthritis, pelvis fracture, protein malnutrition, obsessive compulsive disorder, scoliosis, and kyphosis. Review of FR #100's quarterly Minimum Data Set (MDS) dated [DATE] revealed she had an intact cognition and was dependent on staff for all activities of daily living except eating. Review of Self-Reported Incident #259280 dated 04/12/25 revealed a confused male resident with dementia entered FR #100's room and refused to leave when asked. The male resident became agitated after FR #100 continued to tell him to leave. The male…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-05 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of the self-reported incident (SRI), staff interview, and policy review, the facility failed to timely report an allegation of abuse to the state agency. This affected one (#41) of two residents reviewed for abuse. The facility census was 91. Findings include:Review of Resident #41's medical record revealed an admission date of 03/27/24. Diagnoses included Alzheimer's disease, cognitive communication deficit, major depressive disorder, and hyperlipidemia. Review of Resident #41's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 had severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of 03. Furthermore, Resident #41 was dependent for showers/bathing and required substantial or maximal assistance for toilet hygiene. Review of Resident #41's care plan dated 02/11/26 revealed Resident #41 had a behavior problem and would become physically aggressive during care. Interventions included to administer medications as…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-05 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, review of facility self-reported incidents (SRIs), and review of facility policy, the facility failed to ensure thorough investigations were conducted for allegations of abuse and injuries of unknown origin. Specifically, the facility failed to complete all required investigative steps to determine the cause of the incidents and whether abuse, neglect, or mistreatment occurred. This affected three (#41, #43, and #100) of five residents reviewed for SRI's. The facility census was 91. Findings include:1.Review of Resident #41's medical record revealed an admission date of 03/27/24. Diagnoses included Alzheimer's disease, cognitive communication deficit, major depressive disorder, and hyperlipidemia. Review of Resident #41's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 had severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of 03. Furthermore, Resident #41 was dependent for showers/bathing and required…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-05 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and policy review the facility failed to have the focus interventions in place within the care plan for one (#100) resident who was identified at risk for fractures. This affected one (#100) of two residents reviewed for care planning. The facility census was 91. Findings include:Review of Former Resident (FR) #100's medical record revealed an admission date of 03/20/21 and a discharge date of 09/04/25. Diagnoses included osteoarthritis, protein malnutrition, scoliosis, and kyphosis.Review of Resident #100's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had an intact cognition and was dependent on staff for all activities of daily living except eating. Review of FR #100's most recent care plan revealed it was absent of documentation regarding osteoarthritis and fragility of bones. Review of a FR #100's intradisciplinary team note dated 9/11/25 revealed on 09/03/25 the resident complained of right leg pain after two staff members pulled her…

    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 · D2026-03-05 · 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, medical record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure access to hand hygiene supplies for a resident utilizing a bedside commode (BSC). This affected one (#64) of three residents reviewed for hand hygiene. The facility census was 91. Findings include: Review of the medical record for Resident #64 revealed an admission date of 12/12/25 with diagnoses including bilateral osteoarthritis of the knees, weakness, generalized muscle weakness, abnormalities of gait and mobility, cognitive communication deficit, pneumonia, hypertension, pain in the right and left knee, shortness of breath, hyperlipidemia, hypothyroidism, personal history of malignant neoplasm of the thyroid, lymphedema, neuralgia and neuritis, alcohol dependence, and stage three chronic kidney disease (CKD3). Review of Resident #64's Medicare 5-Day Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15,…

    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 12 citations
  • Potential for harm · Dcited before2026-03-05 · 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 observation, record review, staff interview, and policy review the facility failed to ensure a resident had skin breakdown protection in place as ordered. This affected one (#72) of two residents reviewed for non-pressure skin issues. The facility identified two (#44, #72) residents requiring skin protection related to contractures. The facility census was 91.Findings include:Review of Resident #72's medical record revealed an admission date of 03/08/19. Diagnoses included quadriplegia, neurocognitive disorder, and dementia. Review of Resident #72's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a low cognitive function. Review of Resident #72's most recent care plan revealed the resident was at risk for skin breakdown/skin injury related to decreased mobility. Intervention included to ensure lamb's wool hand rolls were in bilateral hands. The resident was also at risk for impaired functional range of motion related to age, arthritis, dementia, weakness, pain, and contractures…

    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 · D2026-03-05 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and review of the facility policy, the facility failed to ensure incontinence care was completed in a timely manner. This affected one (#11) resident reviewed for incontinence care. The facility census was 91. Review of the medical record for Resident #11 revealed this resident was admitted to the facility on [DATE]. Diagnoses included unspecified dementia, with psychotic disturbance, Neuromuscular dysfunction of bladder, and pneumonitis due to inhalation of food and vomit. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had impaired cognition. This resident was dependent on staff for activities of daily living (ADLs), and incontinence care. Review of the care plan dated 01/29/26 revealed Resident #11 was always incontinent of bowel and had a foley catheter in place. Interventions included monitoring and documenting for signs and symptoms of urinary tract infection (UTI). Further review of the care plan…

    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 · D2026-03-05 · 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, record review, resident interview, staff interview, and policy review, the facility failed to ensure oxygen was administered per the physician's order. This affected two (#17 and #86) of two residents reviewed for oxygen therapy. The facility census was 91. Findings include: 1. Review of Resident #86's medical record revealed an admission date of 03/21/25. Diagnoses included Alzheimer's disease with early onset, type two diabetes mellitus, muscle weakness, and hypertensive chronic kidney disease. Review of Resident #86's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #86 had moderately impaired cognition. Furthermore, Resident #86 required oxygen therapy. Review of Resident #86's physician orders revealed an order for oxygen at two liters per minute (lpm) via nasal cannula as needed for shortness of breath or to keep pulse oximetry above 92%. Review of Resident #86's care plan dated 02/11/26 revealed oxygen therapies and interventions were not included in the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-05 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, and review of facility policy, the facility failed to ensure medications and treatments were administered as ordered. This affected one (#66) of three residents reviewed for medication and treatment administration. The facility census was 91. Findings include: Review of the medical record for Resident #66 revealed an admission date of 08/18/25 with diagnoses including chronic osteomyelitis of the ankle and foot, pressure ulcer of the left heel, type II diabetes mellitus, congestive heart failure, atrial fibrillation, peripheral vascular disease, chronic obstructive pulmonary disease, obesity, generalized muscle weakness, and dependence on a wheelchair.Review of Resident #66's most recent quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS further indicated Resident #66 required assistance with eating and was dependent for all other functional abilities,…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-05 · 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, medical record review, staff interview, and review of the facility policy, the facility failed to ensure Enhanced Barrier Precautions were followed. This affected one (#11) resident reviewed for Enhanced Barrier Precautions. The facility census was 91. FIndings include:Record review for Resident #11 revealed this resident was admitted to the facility on [DATE] . Diagnoses included unspecified dementia, with psychotic disturbance, Neuromuscular dysfunction of bladder, and pneumonitis due to inhalation of food and vomit. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had impaired cognition, was dependent on staff for activities of daily living (ADLs), and incontinence care.Review of the care plan for Resident #11 revealed Resident #11 required Enhanced Barrier Precautions (EBP) related to an indwelling medical device. Interventions included a yellow sign placed on resident's door frame, staff to wear gowns and gloves during high contact 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-08 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, review of a self reported incident (SRI) and subsequent investigation, review of a transcribed interview, policy review, and review of corrective action documentation, the facility failed to ensure residents were free from misappropriation. This affected two (#1 and #2) of three residents reviewed for misappropriation. The facility census was 83. Findings Include: Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included type two diabetes, chronic kidney disease, and major depressive disorder. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #1 was cognitively intact and required extensive assistance of one person for completing her activities of daily living (ADLs). Review of Resident #2's 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · E2022-10-27 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observations and staff interview the facility failed to maintain a sanitary ice machine. This affected all residents except Residents (#3, #4, #27, #34, #75, #77 and #80) who received nectar like fluids and Residents (#40 and #42) who received no nourishment by mouth. The census was 84 residents. Findings Include: Observations on 10/25/22 at 2:50 P.M. revealed black fuzzy substance located on the upper inside frame of the ice machine. This ice machine was in the hall on the unit. Staff used the machine to provide fresh drinks to the residents. Interview on 10/25/22 at 2:56 P.M., the Administrator and Director of Nursing verified that black fuzzy substance identified on the upper frame above the available ice. Interview on 10/25/22 at 3:23 P.M., the Maintenance Director stated he completed general cleaning every Monday and completed deep cleaning once a month. Review of staff signature page for cleaning revealed the ice machine was cleaned on 10/17/22.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-10-27 · 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 observation, staff interview, record review and review of facility policy, the facility failed to provide wound care treatment as ordered for a resident with wounds. This affected one Resident (#78) out of two Residents (#78 and #7) observed for wound care. The facility identified four Residents (#7, #30, #32 and #78) with wounds and who required interventions for wound care. The facility census was 84. Findings include: Review of Resident #78's medical records revealed an admission date of 01/12/22. Diagnosis included cerebral vascular attack (CVA/stroke) with right sided weakness, diabetes, and muscle weakness. Review of Minimum Data Set (MDS) dated [DATE] revealed resident had impaired cognition as well as depression. Review of care plan dated 10/06/22 revealed Resident #78 at risk for skin breakdown related to decreased mobility. Interventions included apply treatments per physician orders, encourage Prevalon boots (pressure reducing boots) while in bed and float heels if resident refuses. 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 · D2019-11-06 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and review of a facility policy, the facility failed to treat a resident with respect and dignity while providing care. This affected one resident (#37) of four residents observed for medication administration. The facility census was 85. Findings include: Medical record review revealed Resident #37 admitted to the facility on [DATE]. Diagnoses included Down Syndrome, early onset Alzheimer's disease and profound intellectual disabilities. Review of the resident's quarterly Minimum Data Set assessment, dated 08/28/19, revealed the resident's cognition was severely impaired. Review of the resident's most recent care plan, revised 09/06/19, revealed Resident #37 had a communication deficit related to impaired cognition and did not speak. Interventions included to talk with the resident while providing care and converse about current events and to explain to the resident the care you were going to perform, prior to performing it, Observation on 11/04/19…

    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 · D2019-11-06 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of the Center for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure a resident's Minimum Data Set (MDS) assessments was accurate. This affected one resident (#37) of 18 residents reviewed for accuracy of assessments. The facility census was 85. Findings include: Medical record review revealed Resident #37 admitted to the facility on [DATE]. Diagnoses included Sown syndrome, early on-set Alzheimer's disease and chronic obstructive pulmonary disease. Further review revealed the resident received Hospice services since 05/24/19. Review of the resident's significant change MDS assessment dated [DATE], section O0100K, asked if the resident was receiving Hospice services. The MDS was coded no which indicated the resident was not receiving Hospice services. Review of her quarterly MDS assessment dated [DATE], section O0100K, asked if the resident was receiving Hospice services…

    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 · D2019-11-06 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure medications were administered according to ordered parameters. This affected two residents (#70 and #60) of four residents reviewed for medications. The facility census was 85. Findings include: 1. Medical record review revealed Resident #70 admitted to the facility on [DATE]. Diagnoses included hypertension, hypotension and chronic atrial fibrillation. Review of Resident #73's physician orders revealed the resident was ordered Metoprolol Tartrate (medication to treat high blood pressure) 25 milligrams (mg), give 0.5 tablet to equal 12.5 mg two times a day (upon rising and at bedtime). Further review of the order revealed staff were supposed to hold the medication for a systolic blood pressure less than 120 millimeters of mercury (mm Hg). Review of the resident's Medication Administration Record (MAR) revealed on 10/16/19, 10/18/19, 10/21/19, 10/22/19, 10/23/19, 10/26/19, 10/27/19, 10/31/19, 11/01/19 and 11/04/19 the resident…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-11-06 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    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 facility policy review, the facility failed to ensure residents received medications as ordered. Observations of 31 medications being administered to four residents with two errors resulted in a medication error rate of 6.4%. This affected on resident (#37) of four residents observed for medication administration. The facility census was 85. Findings include: Medical record review revealed Resident #37 admitted to the facility on [DATE]. Diagnoses included seizure disorder, Down Syndrome, early onset Alzheimer's disease and profound intellectual disabilities. Review of the resident's quarterly Minimum Data Set assessment, dated 08/28/19, revealed the resident's cognition was severely impaired. Review of Resident #37's physician orders revealed the resident was to receive 188 milliliters (ml) of Isosource 1.5 enteral feeding, four times a day. Further review revealed the resident was ordered Keppra solution 500 milligrams (mg) per 5 ml, give 1000…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleSince
FOISY, MEGHANIndividualDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTORsince 10/26/2001
FREAS, HEIDIIndividualDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER; ADP OF THE SNFsince 02/21/2000
HERRON, JILLIndividualDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/03/1999
WESSELL, KELLYIndividualDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTORsince 10/26/2001
ACCUSCRIPTS PHARMACY LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/27/2013
HEALTHCARE SERVICES GROUP INCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/01/2008
RLH CONSULTINGOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/03/2026
THE CLEVELAND CLINIC FOUNDATIONOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/01/2017
EREN, ITRIIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/01/2017
DAYFIELD SENIOR SOLUTIONS, LLCOrganizationADP OF THE SNFsince 06/01/2012
DTW, LLCOrganizationADP OF THE SNFsince 12/31/2001
HEALTHPRO HERITAGE LLCOrganizationADP OF THE SNFsince 04/07/2021
PLANTE & MORAN PLLCOrganizationADP OF THE SNFsince 01/01/2020
HILLIER, ROBINIndividualADP OF THE SNFsince 05/01/1999

CMS files one row per role, so the 28 rows in the source record cover these 14 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

8 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.

$8.4M
Net patient revenuemost recent cost report
-2.8%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 64%Medicare 2%Other / private 33%

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

$277per resident / day
operating cost
$8,430per month
≈ monthly operating cost
$270per 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 365508. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-05, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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