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Eagle Pointe Skilled Nursing & Rehab

87 Staley Road, Orwell, OH 44076 · For profit - Corporation · 60 certified beds · (440) 437-7171 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citations on record (F0600, F0602, F0608, F0609, F0610) — most recent Apr 20263 immediate-jeopardy citations
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has abuse, neglect, or exploitation citations (F0600, F0602, F0608, F0609, F0610) — most recent Apr 2026
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 3 immediate-jeopardy problems — the most serious level
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its payroll-based staffing rating is low (1/5)
  • nursing-staff turnover (57%) runs well above the national median (45%)

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

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

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

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

Location & what’s nearby

Hospital
Urgent care / clinic
3092 N Main St · (440) 969-3560 · Call to confirm hours
Pharmacy
1949 Forman Rd · (440) 992-1122 · Call to confirm hours
Grocery
3119 Sodam Rd
Park
Western Reserve Greenway Trail Orwell Ohio Usa · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

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

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased0.0%5.3%15.4%check this — see note marked star below the table
Long-stay residents who lose too much weight0.0%6.2%5.4%check this — see note marked star below the table
Long-stay residents with a catheter left in their bladder0.0%0.2%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.4%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms52.1%30.1%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.9%3.2%3.3%better
Long-stay residents whose ability to walk worsened1.4%6.1%16.1%better than state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication39.7%25.5%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%94.5%95.3%typical
Long-stay residents with pressure ulcers0.0%3.4%4.7%check this — see note marked star below the table
Long-stay residents with worsening bladder/bowel control20.7%21.4%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table5.2%8.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

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.

Staffing

0.58
RN hours/ resident / day
0.65
LPN hours/ resident / day
1.97
Aide hours/ resident / day
3.19
Total nurse hours/ resident / day
0.39
RN hoursweekends
57.1%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 60 beds and averages 54.0 residents a day — about 90% occupied, or roughly 6 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 3.19 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.58 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.97 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.71 hrs/resident/day on weekends vs 3.39 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.65 to 0.39 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 57% is well above 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

3
deficiencies at the latest standard inspection (2025-03-20)
5
at the previous standard inspection (2022-10-13)

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.

Inspection deficiencies

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

ABCDEFGHIJKL

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

27 citations, most serious first. The 14 most serious are shown; the remaining 13 are one tap away and print in full.

  • Immediate jeopardy · K2019-10-21 · tag F0608 — failed to report suspected crimes — pattern
    Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting.
    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, facility investigation, and associated investigation documents, the facility policy titled Freedom from Abuse, Neglect, and Exploitation, and The Elder Justice Act and Reporting Suspected Crimes Against Residents, and interview with staff the facility failed to implement the facility abuse policy following an allegation of resident to resident sexual abuse. This resulted in Immediate Jeopardy and the likelihood of serious physical and emotional harm for one cognitively impaired resident (Resident #38) when the administrator became aware of an allegation of sexual abuse by a resident with known sexual behaviors (Resident #47) and failed to report the allegation to local authorities. This affected one of five residents reviewed relative to investigations of physical or sexual abuse. The facility identified 12 additional cognitively impaired residents the alleged perpetrator had access to (Residents #5, #11, #21, #24, #25, #26, #30, #33, #35, #40, #41, and #196). The facility…

    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
  • Immediate jeopardy · K2019-10-21 · tag F0609 — failed to report abuse allegations — pattern
    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 review of the medical record, facility investigation, and associated investigation documents, the facility policy titled Freedom from Abuse, Neglect, and Exploitation, and The Elder Justice Act and Reporting Suspected Crimes Against Residents, and interview with staff the facility failed to implement the facility abuse policy following an allegation of resident to resident sexual abuse. This resulted in Immediate Jeopardy and the likelihood of serious physical and emotional harm for one cognitively impaired resident (Resident #38) when the administrator became aware of an allegation of sexual abuse by a resident with known sexual behaviors (Resident #47) and failed to report the allegation to the State Agency as required. This affected one of five residents reviewed relative to investigations of physical or sexual abuse. The facility identified 12 additional cognitively impaired residents the alleged perpetrator had access to (Residents #5, #11, #21, #24, #25, #26, #30, #33, #35, #40, #41, and #196).…

    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
  • Immediate jeopardy · K2019-10-21 · tag F0610 — failed to investigate and act on abuse reports — pattern
    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 review of the medical record, facility investigation, and associated investigation documents, the facility policy titled Freedom from Abuse, Neglect, and Exploitation, and The Elder Justice Act and Reporting Suspected Crimes Against Residents, and interview with staff, resident, and resident families the facility failed to implement their abuse policy following an allegation of resident to resident sexual abuse. This resulted in Immediate Jeopardy and the likelihood of serious physical and emotional harm for one cognitively impaired resident (Resident #38) when the administrator became aware of an allegation of sexual abuse by a resident with known sexual behaviors (Resident #47) and failed to ensure adequate monitoring of the alleged resident perpetrator, thoroughly investigate the allegation and report the allegation to law enforcement and the State Agency. This affected one of five residents reviewed relative to investigations of physical or sexual abuse. The facility identified 12 additional…

    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
  • Actual harm · G2024-01-10 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of psychotropic medication information, facility policy review and interview, the facility failed to prevent a significant medication error for Resident #26 when the resident's psychotropic medication, for reducing risk of recurrent suicidal behavior with schizophrenia was not administered as ordered by the physician from 11/20/23 until 12/06/23. The facility also failed to ensure the physician was notified timely that the medication was unavailable for administration. Actual Harm occurred on 12/07/23 when Resident #26 was admitted to the hospital with psychosis (having increased behaviors and hallucinations), suicidal ideations, threatening to kill herself and slit her throat with a knife as a result of the missed doses of the psychotropic medication, Clozapine. This affected one resident (#26) of four residents reviewed for medication administration. The facility census was 52. Findings Include: Review of the medical record for Resident #26 revealed an initial admission date 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-30 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident and staff interviews and facility policy review, the facility failed to make prompt efforts and resolve a resident grievance involving staff smelling of marijuana while providing care. This affected one resident (Resident #21) of two residents reviewed for resident concerns. The facility census was 53. Findings include:Review of the medical record for Resident #21 revealed an admission date of 07/15/23 with diagnoses including pan lobular emphysema, chronic obstructive pulmonary disease (COPD), insomnia, dependence on respirator, muscle wasting, heart failure, type two diabetes, and anxiety. Review of the facility document titled Witness statement dated 03/19/26 and authored by Unit Manager (UM) #336 revealed Resident #21 notified UM #336 that Certified Nursing Assistant (CNA) #315 and CNA #339 smelled like marijuana. UM #336 stated she could smell a faint odor and that the CNA did not appear impaired. UM #336 stated she spoke with CNA #315 and #339 and told them it was not…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-04-08 · tag F0602 — failed to protect residents from theft of their belongings — pattern
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on record review, interview, observation, self-reported incident (SRI) review and facility policy review, the facility failed to ensure residents were free from misappropriation. This affected five Residents (#20, #35, #46, #54, and #55) out of six residents reviewed for misappropriation. The facility census was 53.Findings include:1. Review of the closed medical record for Resident #54 revealed an admission date of 02/19/24. She passed away at the facility on 08/28/25. Her diagnoses included rheumatoid arthritis, chronic pain, and chronic obstructive pulmonary disease (COPD). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #54 had intact cognition and was on a scheduled pain medication regimen that included opioids (medications prescribed to treat severe or persistent pain, but they can also be addictive). Review of July 2025 physician…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · D2026-04-08 · 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 record review, interviews, review of a grievance form, and facility policy review, the facility failed to ensure that care was provided in a manner that maintained the resident's dignity and honored the resident's right to be informed of and refuse treatment. This failure affected one resident (Resident #20) of three residents reviewed for resident rights. The facility census was 53.Findings include:Record review revealed Resident #20 was admitted on [DATE] with diagnoses including panlobular emphysema, acute and chronic respiratory failure, and severe morbid obesity.Review of a grievance form dated 11/10/25 revealed Resident #20 reported that Certified Nursing Assistant (CNA) #625 used vinegar on him during his shower. The facility investigated the incident and educated CNA #625 on customer service and patient care. The grievance documentation indicated vinegar was not to be used with Resident #20 in the future, and CNA #625 was removed from his care assignment.Review of nurse's notes dated 11/01/25…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-08 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, review of a grievance form and facility policy review, the facility failed to ensure treatments were provided in accordance with professional standards and failed to obtain a physician's order prior to administering a topical treatment. This resulted in vinegar being applied to Resident #20 without a physician's order and against the resident's expressed refusal. This deficient practice affected one (Resident #20) of three residents reviewed for physician-ordered treatments. The facility census was 53.Findings include:Review of medical record for Resident #20 revealed he admitted on [DATE] with diagnoses including panlobular emphysema, chronic obstructive pulmonary disease (COPD), obstructive sleep apnea (OSA), insomnia, congestive heart failure (CHF), gastroesophageal reflux disease (GERD), deep vein thrombosis (DVT), Lupus anticoagulant syndrome, anemia, muscle wasting and atrophy, difficulty walking, pain, major depressive disorder, anxiety, iron deficiency, bilateral…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-20 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and review of the facility policy, the facility failed to ensure labs were obtained as ordered for Resident #5. This affected one resident (#5) out of five residents reviewed for unnecessary medications/labs. The facility census was 50. Findings include: Review of the medical record for Resident #5 revealed an admission date of 02/25/23 with diagnoses including diabetes, dementia, hypertension, and seizures. Review of the lab work completed from 02/25/23 to 03/18/25 revealed there was no documented evidence a ferritin level (lab that indicated the amount of iron stored in the body) or a Keppra level (lab that monitored the anticonvulsant (seizure) drug level) was completed as ordered. A Vitamin D level was completed on 07/15/24 and was 17 indicating it was low (normal range was 30 to 100 nanograms (ng)/ milliliter (mL). There were no further Vitamin D levels noted on review. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had intact…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-20 · tag F0699 — isolated
    Provide care or services that was trauma informed and/or culturally competent.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and facility policy review, the facility failed to provide culturally competent, trauma-informed care in accordance with professional standards of practice or account for experience and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of Resident #52's post-traumatic stress disorder (PTSD). This affected one resident (#52) of two residents reviewed for trauma informed care. The facility census was 50. Findings include: Review of the medical record revealed Resident #52 was admitted to the facility on [DATE] with diagnoses of PTSD, morbid (severe) obesity due to excess calories, and anxiety disorder. Review of the undated comprehensive care plan revealed the absence of a care plan addressing PTSD or associated triggers and the absence of a psychosocial assessment for Resident #52. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #52 was cognitively intact with a Brief Interview for Mental Status (BIMS) score…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-20 · tag F0810 — isolated
    Provide special eating equipment and utensils for residents who need them and appropriate assistance.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review and review of the facility policy, the facility failed to ensure Resident #43 had adaptive equipment as ordered when eating. This affected one resident (#43) out of one resident reviewed for adaptive equipment when eating. This had the potential to affect seven residents (#5, #10, #11, #17, #30, #32, and #43) that had orders for adaptive equipment while eating. The facility census was 50. Findings included: Review of the medical record for Resident #43 revealed an admission date of 11/02/23 with diagnoses including multiple sclerosis, muscle weakness, and schizoaffective disorder. Review of the March 2025 physician's orders revealed Resident #43 had an order dated 11/03/23 to have built-up utensils and a two handled mug for all meals. Review of the care plan dated 03/11/25 revealed Resident #43 had a nutritional problem related to excessive energy intake and self-feeding deficit which required adaptive equipment with meals. Interventions included occupational therapy screening and providing adaptive equipment for feeding including…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-03-26 · tag F0803 — failed to meet residents' dietary needs — widespread
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of facility documents, the facility failed to ensure they had a three-day emergency supply of food as required. This had the potential to affect all 54 residents. The facility identified no residents as receiving nothing by mouth. The census was 54. Findings include: Observation during initial tour of the kitchen on 03/25/24 from 8:03 A.M. to 8:25 A.M. with Dietary [NAME] (DC) #355 and Dietary Aide (DA) #356 revealed a minimal supply of foods in dry and cold storage areas of the kitchen. The walk-in cooler and freezer revealed the shelves held minimal foods available to cook for the meals. The bread rack had multiple empty shelves with a few packages of bread products. There was no instant powdered milk or canned meat items available for an emergency food supply. Dietary Aide #356 at the time of observation confirmed the facility did not have a three-day emergency supply of food. Interview on 03/25/24 at 8:39 A.M. with Dietary Manager (DM) #350 confirmed the facility…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-03-26 · tag F0812 — failed to store, cook, and serve food safely — widespread
    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 — an excerpt from the official record, may be distressing

    Based on observation, interviews, review of facility records and review of facility policy, the facility failed to ensure the low temperature dish machine was being appropriately monitored for levels of chemical sanitizer, and the kitchen was clean and sanitary. This had the potential to affect all 54 residents. The facility identified no residents as receiving nothing by mouth. The census was 54. Findings include: 1. Observation of the low temperature dish machine on 03/25/24 from 9:05 A.M. to 9:13 A.M. with Regional Director (RD) #353 revealed the dish machine had not met the recommended sanitation level of 50 parts per million (ppm) when RD #353 tested the dish machine's rinse water with a QAC QR Code 2951 sanitation test strip. The strip turned a pale green color which indicated the sanitizer level did not meet the sanitation level of 50 ppm. Further observation of the low temperature dish machine and interview on 03/25/24 at 2:15 P.M. with RD #353 revealed when RD #353 used a QAC QR Code 2951 test strip to test the sanitation level of the dish machine, the test strip turned 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-13 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure Resident #4 was provided a reasonable accommodation to enter the facility and did not ensure Resident #50's wheelchair was serviced and repaired in a timely manner. This affected two residents (Residents #4 and #50) of two residents reviewed for accommodation of needs. Findings include: 1. Review of the medical record for Resident #4 revealed an admission date of 02/22/22 with diagnoses including chronic obstructive pulmonary disease (COPD), anemia, nicotine dependence, anxiety disorder and morbid obesity. Review of the smoking assessment dated [DATE] revealed the resident was an unsupervised smoker, but required assistance getting outside in her wheelchair. Review of Resident #4's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact. She was totally dependent on two people for transfers and she required extensive assistance of two people for bed mobility, dressing and toilet…

    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
Show the remaining 13 citations
  • Potential for harm · D2022-10-13 · 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 and staff interview, the facility failed to ensure resident care plans were revised to reflect current resident medical/behavioral conditions. This affected one resident (Resident #34) of eight residents reviewed for elopement care plans. Findings include: Review of the medical record for Resident #34 revealed an admission date of 05/01/22 with diagnoses including bipolar disorder, depression, amnesia and post traumatic stress disorder (PTSD). Review of the progress note dated 06/08/22 and timed 5:44 P.M. revealed Resident #34 was walking in town when a police officer found her. When Resident #34 returned to the facility, the Director of Nursing (DON) was notified of the incident and contacted the guardian. It was agreed Resident #34's privileges to leave the facility would be revoked. Review of the care plan dated 08/23/22 revealed Resident #34 was a low risk for elopement. Interventions included ensuring safety during periods of confusion or anxiety, unsupervised smoke breaks and being…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-10-13 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, and record review, the facility failed to ensure Resident #41's bowel pattern was effectively managed. This affected one resident (Resident #41) of two residents reviewed for constipation. Findings include: Review of medical record for Resident #41 revealed an admission date of 12/21/21 and diagnoses included morbid obesity, heart failure, chronic respiratory failure, diabetes, and kidney failure. He did not have a diagnosis of constipation. Review of care plan dated 12/22/21 revealed Resident #41 had an activities of daily living self-care performance deficit related to impaired balance, and morbid obesity. Interventions included he required staff assist with transfers, bed mobility, and toileting. Review of comprehensive care plan dated 12/22/21 revealed Resident #41 did not have a care plan for constipation. Review of electronic medical record dated from 09/14/22 to 10/13/22 under bowel continence task bar revealed Resident #41 had a large bowl movement on 09/14/22 but then did not have another bowel movement until 09/22/22 (seven days later) and it 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-13 · 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 interview and record review, the facility failed to ensure Resident #39 received her medications consistently per physician orders. This affected one resident (Resident #39) of eight residents reviewed for pharmacy services. Findings include: Review of the medical record for Resident #39 revealed she was admitted on [DATE] with diagnoses including chronic pancreatitis, major depressive disorder, anxiety, rheumatoid arthritis, type II diabetes and bipolar disorder. Review of physician orders revealed the resident received Actemra Solution Prefilled Syringe 162 milligrams (mg)/0.9 milliliter (ml) subcutaneously one time a day every 14 days related to rheumatoid arthritis, Motegrity tablet 2 mg in the morning related to constipation, and Vyvanse Capsule 30 mg tablet and 40 mg tablet, each once a day related to attention deficit-hyperactivity disorder. Review of the annual Minimum Data Summary (MDS) 3.0 of 09/24/22 revealed Resident #39 was cognitively intact, had severe depression, was independent for…

    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 · D2022-10-13 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, observation, and record review, the facility failed to ensure Resident #31's insulin was dated after it was opened. This affected one resident (Resident #31) out of four residents (Resident #5, #28, #31, #39) that received insulin on the north cart two. Findings included: Review of medical record for Resident #31 revealed an admission date of 10/30/18 and her diagnoses included diabetes, morbid obesity, and chronic obstructive pulmonary disease. Review of care plan dated 11/05/18 revealed Resident #31 had diabetes and her interventions included administer insulin per physician orders, and check blood glucose levels per orders. Review of physician order dated 04/29/22 revealed Resident #31 had an order for Novolog insulin inject six units subcutaneously (SQ) three times a day before meals that was scheduled for 5:00 A, M., 12:00 P.M. and 5:00 P.M. Observation on 10/12/22 at 11:32 A.M. revealed Resident #31's Novolog insulin was undated when Licensed Practical Nurse (LPN) #210 took out the insulin out of north cart two. Observation then revealed LPN #210…

    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 · F2019-10-21 · tag F0835 — failed to run the facility competently — widespread
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    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 interviews, review of facility policies and procedures, and facility Self-Reported Incident (SRI) history, the facility administration failed to ensure facility abuse prevention policies were implemented and appropriate measures were taken in response to an allegation of sexual abuse involving Resident #38. The administrative failure resulted in incidents of Immediate Jeopardy at Data Tags F607, F608, F609, and F610 for not implementing the facility abuse policy, reporting the allegation to local authorities, notifying the State Agency, ensuring adequate monitoring of the alleged resident perpetrator (Resident #47), and thoroughly investigating the allegation. This affected one (Resident #38) of five residents reviewed relative to investigations of physical or sexual abuse and had the potential to affect all 46 residents residing in the facility. Findings include: Review of the medical record revealed Resident #38 was admitted on [DATE] with diagnoses including vascular…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2019-10-21 · tag F0868 — widespread
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview and record review the facility failed to ensure Quality Assessment and Assurance (QAA) meetings occurred quarterly. This had to the potential to affect all residents. The facility census was 46. Findings include: Interview on 10/10/19 at 3:33 P.M. with the Administrator revealed QAA prior to her appointment as administrator had occurred quarterly. The Administrator stated the meetings were now held monthly and included herself, the management team, Director of Nursing, and the Medical Director. The Administrator stated quarterly the ancillary representatives such as pharmacy would attend and the next quarterly meeting would be sometime in October 2019. Review of the QAA meeting sign in sheets revealed for the fourth quarter dated February 2019 key staff had attended. The first quarter sign in sheet dated May 2019 revealed key staff had attended. There was no sign in sheet or evidence for the second quarter meeting for July 2019. Interview on 10/10/19 at 4:05 P.M. with the Administrator revealed she was unable to produce any evidence of a meeting for July 2019.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2019-10-21 · tag F0607 — failed to have anti-abuse policies — pattern
    Develop 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, facility investigation, and associated investigation documents, the facility policy titled Freedom from Abuse, Neglect, and Exploitation, and The Elder Justice Act and Reporting Suspected Crimes Against Residents, and interview with staff, resident, and resident families the facility failed to implement the facility abuse policy following an allegation of resident to resident sexual abuse. This affected one (#38) of five residents reviewed relative to investigations of physical or sexual abuse. The facility identified 12 additional cognitively impaired residents the alleged perpetrator had access to (Residents #5, #11, #21, #24, #25, #26, #30, #33, #35, #40, #41, and #196). The facility census was 46. Findings include: Review of the medical record revealed Resident #38 was admitted on [DATE] with diagnoses including vascular dementia with behavioral disturbance, depression with anxiety, arthritis, and hypertension. Review of the quarterly Minimum Data Set (MDS) 3.0…

    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 · Ecited before2019-10-21 · 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 observation and interview, the facility failed to ensure bread stored in the kitchen was not expired and free from mold. This had the potential to affect all residents except Resident #25 who received nothing by mouth. The facility census was 46. Findings include: Tour of the kitchen on 10/06/19 at 8:30 A.M. revealed on the bread rack, four bags of buns that had expired on 09/28/19 and one of the bag of buns had a moderate amount of mold on the bottom. At this time Dietary Aide (DA) #207 verified the findings. Review of the facility policy titled Food Receiving and Storage revised July 2014 revealed food shall be received and stored in a manner that complies with safe food handling practices.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-10-21 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Resident #18's physician was notified when the resident was found with alcohol in his room on two instances. This affected one of three residents reviewed for physician notification. The census was 46. Findings include: Review of the medical record for Resident #18 revealed the resident was admitted on [DATE] with diagnoses including but not limited to alcohol dependence, unspecified convulsions, Parkinson's disease, acute respiratory failure with hypoxia, diabetes , anxiety disorder, manic episode with psychotic symptoms and hemiplegia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact with no behaviors, required extensive assist of two for transfers and toileting and had one fall with injury. Review of the care plan dated 08/22/19 revealed care areas for impaired thought process related to traumatic brain injury, behavior problem as evidence by making sexually inappropriate comments to…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-10-21 · 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

    Based on observation and interview the facility failed to maintain a homelike environment. This affected one (Resident #36) of 46 residents reviewed for environmental concerns. The facility also failed to maintain ambient temperatures within 71 and 81 degrees Fahrenheit (F) on the C wing on the South side hall. This affected two (Residents #14 and #43) of eight residents who resided on the C wing of the South side hall. Findings include: 1. Interviews on 10/06/19 at 10:39 A.M. and 10:51 A.M. with Residents #14 and #43 revealed the C wing of the South side hall was cold. Resident #43 stated it had felt cold since early September. Residents #14 and #43 stated they both reported the cold temperature to staff. Observation on 10/06/19 10:49 A.M. with Maintenance Director (MD) #214 of the thermostat located on C wing of the South side hall revealed the inside temperature was 69 degrees F. At this time MD #214 confirmed the temperature and stated he had not turned on the boiler and that this side of the building ran on the boiler. Interview on 10/08/19 at 8:34 A.M. and 10:20 A.M. with the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-10-21 · 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 interview, review of the medical record, review of a personnel file, and review of the abuse policy, the facility failed to protect a resident with impaired judgment and impulse control deficits from a sexual relationship with an employee. This affected one (Resident #47) of five residents reviewed for abuse. The facility census was 46. Findings include: Review of the closed record for Resident #47 revealed he was admitted on [DATE]. His diagnoses included traumatic brain injury, major depressive disorder, anxiety disorder, and bipolar disorder. Resident #47 was discharged to another nursing home on [DATE]. The resident's father was his legal guardian. Review of a progress note dated 01/06/19 at 8:47 A.M. revealed a female visitor was observed leaving Resident #47's room. Resident #47 stated female visitor spent the night in his room. A progress note dated 01/06/19 at 8:00 P.M. noted resident has a female visitor at this time in his room. Visitor noted wearing pajamas. Review of a psychiatric follow up…

    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 · D2019-10-21 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview the facility failed to develop a smoking care plan for Resident #3 and revise Resident #18 's care plan regarding alcohol use. This affected two (Residents #3 and #18) of 16 residents reviewed for care plans. Findings include: 1. Record review of Resident #3's medical record revealed an admission date of 06/19/19. Diagnoses included unspecified lack of coordination, muscle weakness, nicotine dependence unspecified uncomplicated, and chronic obstructive pulmonary disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition, required extensive assistance of two staff for bed mobility, transfers, and toilet use, and used tobacco. Review of the smoking assessments dated 06/28/19 and 09/26/19 revealed Resident #3 required one on one supervision and was determined to be supervised smoker. Review of Resident #3's current care plan on 10/07/19 revealed no information related to supervised smoking. Observation…

    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 · D2019-10-21 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure restorative programing to maintain residents' abilities for activities of daily living (ADL) and/or ambulation following therapy. This affected two (Residents #17 and #38) of two residents reviewed for ADLS. The facility census was 46 residents. Findings include: 1. Review of the record revealed Resident #38 was admitted on [DATE] with diagnoses including dementia with behavioral disturbance, diabetes, and anxiety disorder. The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident had severe cognitive impairment and needed limited physical assistance for transfers, dressing, personal hygiene, and toilet use. The quarterly MDS 3.0 assessment dated [DATE] revealed Resident #38 had a decline in activities of daily living. She needed extensive physical assistance with dressing, personal hygiene and toilet use. Resident #38 received occupational therapy (OT) for the decline in activities of daily living…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to AOM HEALTHCARE — 20 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 52.7+0.3 vs chain
Health inspection 3 of 52.3+0.7 vs chain
Staffing 1 of 51.6-0.6 vs chain
Quality measures 5 of 54.8+0.2 vs chain
The other 19 homes this chain runs (chain average 2.7★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
POINTE WOODS INVESTMENT LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 04/01/2017
GOLDSTEIN, JEFFERYIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST33%since 04/01/2017
SHERMAN, ALEXANDERIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL33%since 04/01/2017
SHERMAN, SAMUELIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL33%since 04/01/2017

CMS files one row per role, so the 6 rows in the source record cover these 4 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.

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.

$6.0M
Net patient revenuemost recent cost report
-0.5%
Operating marginrevenue minus expenses
$704K
Related-party expense12% of expenses
Who pays — share of resident-days
Medicaid 88%Medicare 4%Other / private 8%

About 88% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $704K paid to related parties — landlords or management companies under common ownership — equal to about 12% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

$323per resident / day
operating cost
$9,832per month
≈ monthly operating cost
$322per 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 366270. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-20, 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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