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Meadows Of Ottawa The

147 Putnam Parkway, Ottawa, OH 45875 · For profit - Corporation · 86 certified beds · (419) 523-4092 Medicare & Medicaid certified

Call the home — (419) 523-4092 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (26) — 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

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

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

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 3 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
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
102 Putnam Pkwy · (419) 523-9632 · Call to confirm hours
Pharmacy
1720 N Perry St · (419) 523-9205 · Call to confirm hours
Grocery
10586 State Route 15 · (419) 969-4035 · Call to confirm hours
Park
171 North Dr · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 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 3 to 4 stars. From monthly CMS archive snapshots.

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

Overall rating4★
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 increased8.2%5.3%15.4%worse than state — see note marked double-dagger below the table
Long-stay residents who lose too much weight3.0%6.2%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.2%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.4%0.4%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms16.2%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 injury10.3%3.2%3.3%worse
Long-stay residents whose ability to walk worsened5.7%6.1%16.1%typical for the state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication31.9%25.5%18.9%worse
Long-stay residents given the seasonal flu vaccine95.9%94.5%95.3%typical
Long-stay residents with pressure ulcers1.5%3.4%4.7%better
Long-stay residents with worsening bladder/bowel control22.4%21.4%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table8.5%8.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.5%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine82.7%75.6%79.4%typical
Short-stay residents rehospitalized after admission22.1%24.9%22.6%typical
Short-stay residents with an outpatient ER visit7.4%12.9%12.0%better
Long-stay hospitalizations per 1,000 resident days1.791.731.67typical
Long-stay outpatient ER visits per 1,000 resident days0.841.801.80better

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.

54.2% 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 135 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

54.2%U.S. median 51.5%
Got home and stayed home
8.8%U.S. median 10.7%
Went back to hospital
69.4%U.S. median 56.6%
Met the expected recovery
0.39U.S. median 0.31
Therapy hours / resident / day
0.21hours / resident / day
Physical therapy
0.15hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 69.4% 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 98 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 0.39 therapist hours per resident per day in 2026Q1 — more than 68% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% 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 SNF54.2%CMS range 45.8–62.151.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF8.8%CMS range 6.6–12.710.7%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 discharge69.4%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 discharge61.2%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 discharge50.0%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 identified93.6%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 discharge98.4%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.9%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 worsened0.9%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 hospitalization6.5%CMS range 3.7–10.57.1%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

0.75
RN hours/ resident / day
0.52
LPN hours/ resident / day
1.93
Aide hours/ resident / day
3.20
Total nurse hours/ resident / day
0.43
RN hoursweekends
39.2%
Total nursing turnover
13.3%
RN turnover

How full it usually is: this home is certified for 86 beds and averages 80.2 residents a day — about 93% 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 3.20 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.75 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.93 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 2.73 hrs/resident/day on weekends vs 3.39 on weekdays — 19% thinner on weekends. RN hours go from 0.88 to 0.43 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 39% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

6
deficiencies at the latest standard inspection (2025-01-30)
12
at the previous standard inspection (2023-10-31)

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.

26 citations, most serious first. The 11 most serious are shown; the remaining 15 are one tap away and print in full.

  • Actual harm · G2025-01-30 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, interview with wound care nurse practitioner, and facility policy review, the facility failed to ensure wound monitoring and physician prescribed wound treatments were administered as ordered. Actual Harm occurred when Resident #71 fell from his wheelchair and sustained a laceration to the head which compromised a preexisting head wound. Resident #71 was evaluated at the hospital and returned to the facility with a hemostatic bandage dressing in place. The dressing remained in place for seven days without being changed or evaluated. The dressing was discovered to be severely adhered to the scalp, required debridement to remove embedded dressings and found to have a large amount of foul-smelling drainage between layers of dressings and wound with exposed bone. This affected one (#71) of three residents reviewed for the application of wound treatments in a facility census of 80. Findings include: Review of Resident #71's medical record revealed 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 · D2025-01-30 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, family interview, and staff interview, the facility failed to ensure residents who were dependent on staff for activities of daily living (ADL) care received adequate assistance with personal hygiene. This affected one (#59) of four residents reviewed for ADL care. The facility census was 80. Findings include: Review of the medical record revealed Resident #59 was admitted on [DATE]. Diagnoses included paraplegia, injury to sacral spinal cord, other front temporal neurocognitive disorder, dementia, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #59 was rarely understood and dependent on staff for assistance with personal hygiene. Review of the care plan dated 10/04/22 revealed Resident #59 had paraplegia and required one person assistance with ADL care. Observation on 01/27/25 at 10:38 A.M. revealed Resident #59 had unshaven facial hair on face and neck. Interview on 01/27/25 at 10:40 A.M. with Resident #59's…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-30 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, resident and staff interview, and review of facility policies, the facility failed to ensure interventions for residents with pressure ulcers were applied correctly. This affected one (#75) of three residents reviewed for pressure ulcers. The facility census was 80. Findings include: Review of the medical record revealed Resident #75 was admitted on [DATE]. Diagnoses included polyosteoarthritis, fracture of second lumbar vertebra, chronic kidney disease, anorexia, muscle weakness, osteoarthritis, and retention of urine. Review of the Minimum Data Set (MDS) assessment, dated 10/31/24, revealed Resident #75 was severely cognitively impaired. The resident required substantial assistance from staff for toileting, showers, upper and lower body dressing, and personal hygiene. Review of the most recent care plan revealed Resident #75 required encouragement and assistance with turning and repositioning every two hours with heel protector moon boots on while in bed at all…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-30 · 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 resident and staff interview, medical record review, and interview with pharmacy staff, the facility failed to ensure medications were available and administered as physician ordered. This affected one (#23) of one resident reviewed for pain management. The facility census was 80. Findings include: Review of Resident #23's medical record revealed an admission date of 06/10/24. Diagnoses included pinched nerve in the lumbar region, traumatic muscle injury, osteoporosis, spinal stenosis, chronic pain, chronic cluster headache, tremor, and opioid dependence with opioid induced psychotic disorder with delusions. Review of Resident #23's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating Resident #23 was cognitively intact. Resident #23 displayed no behaviors during the review period. Resident #23 received scheduled and as needed (PRN) pain medication. At the time of the review Resident #23 reported her pain was almost constant and occasionally 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-30 · 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 resident interview, medical record review, staff interview, and review of facility policy, the facility failed to ensure blood sugar levels were obtained and insulin was administered according to physician orders, resulting in a significant medication error. This affected one resident (#47) of one resident reviewed for blood sugar checks and insulin. The facility census was 80. Findings include: Review of Resident #47's medical record revealed an admission date of 10/28/21. Diagnoses included type II diabetes mellitus and morbid obesity. Review of Resident #47's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating Resident #47 was cognitively intact. Review of Resident #47's care plan revised 01/22/25 revealed supports and interventions for the risks of hypo/hyperglycemia related to diabetes mellitus. Interventions included diet per order, monitor blood sugars as ordered and provide medications as ordered. Review of Resident #47's…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-30 · 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 facility policy, the facility failed to ensure enhanced barrier infection control precautions were implemented as ordered. This affected one (#73) of 23 residents reviewed for infection control practices in a facility census of 80. Findings include: Resident #73 admitted to the facility on [DATE] with the diagnoses including, hemiplegia and hemiparesis following non-traumatic intracranial hemorrhage, aphasia, dysphagia, acute respiratory failure, hypertension, history of tracheostomy, and percutaneous endoscopic gastrostomy tube. According to the most current Minimum Data Set assessment dated [DATE] Resident #73 was assessed with severely impaired cognition, dependent on staff for the completion of activities of daily living, received nutrition via feeding tube, and mechanically altered diet. On 01/22/25 a nursing plan of care was implemented to address Resident #73 required Enhanced Barrier Precautions (EBP) during high-contact care related 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-08 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, staff interview and review of facility training, the facility failed to ensure passive range of motion (PROM) was completed as ordered. This affected one (#1) of three residents reviewed for range of motion. The facility census was 83. Findings include: Review of Resident #1's medical record revealed an admission date of 09/25/19. Diagnoses included acute respiratory failure, quadriplegia, emphysema, heart disease with heart failure, dysphagia, post-traumatic stress disorder, anxiety disorder, personality disorder, and delirium. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #1 was cognitively intact. Resident #1 had impaired upper and lower extremities. Resident #1 required extensive assistance with bed mobility, transfer, and toilet use. Resident #1 displayed rejection of care behaviors one to three days during the review period. Review of Resident #1's…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-10-31 · 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, staff interview, and review of the facility policy, the facility failed to ensure food was stored appropriately. This had the potential to affect all residents residing in the facility. The facility identified all residents received food from the kitchen. Additionally, the facility failed to ensure staff used appropriate hand hygiene when handling ready-to-eat foods. This affected three (Residents #9 #128, #6) of three residents observed for meal preparation. The facility census was 80. Findings include: 1. Observations on 10/23/23 beginning at 8:27 A.M. in the freezer revealed a box of chicken nuggets open to air, a plastic tub labeled taco meat with the lid off, and a torn open bag of breaded fish filets. Interview with [NAME] #178 during the observation confirmed the items were open. Continued observation of the walk-in refrigerator revealed a bag of chopped lettuce open to air, a box of bacon lined with a plastic bag. The plastic bag was completely open and exposing all bacon in the box to the air, and containers of raspberries, blackberries and…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-10-31 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, resident interview, and staff interview, the facility failed to ensure meat was palatable. This affected four residents (#6, #30, #38 and #68) and had the potential to affect all residents on a regular diet. The facility identified 23 residents were not on a regular diet (#4, #7, #11, #12, #14, #15, #16, #19, #22, #24, #26, #31, #34, #40, #48, #53, #61, #64, #71, #72, #128, #228, and #229). The facility census was 80. Findings include: Observations on 10/23/23 beginning at 12:03 P.M. in the main dining room during the noon meal revealed the main meal provided was chopped steak with mushroom gravy, red skin mashed potatoes, and vegetable medley. Observation on 10/23/23 at 12:05 P.M. in the restorative dining room revealed Resident #6 was eating her lunch unassisted. State Tested Nurse Aide (STNA) #165 was observed telling Resident #6 to slow down and chew or you're going to choke. The meat is very tough today. Observation on 10/23/23 at approximately 12:10 P.M. in the main dining room revealed Resident #38 received her meal. Resident #38 was observed to have…

    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 · D2023-10-31 · 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 medical record review, observation, resident and staff interviews, and facility policy, the facility failed to ensure residents had access to call lights. This affected one (Resident #49) of one reviewed for call lights. The facility census was 80. Findings include: Review of the medical record revealed Resident #49 was admitted on [DATE]. Diagnoses included hypertensive heart disease with heart failure, iron deficiency anemia, type two diabetes mellitus, and hypothyroidism. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Resident #49 required extensive one person assistance with bed mobility, transfers, locomotion on and off unit, dressing, and personal hygiene. Review of the care plan dated 11/18/21 revealed Resident #49 was at risk for incontinence and falls with interventions to keep the call light within reach. Interview on 10/23/23 at 12:45 P.M. with Resident #49 revealed the resident did not have access to her call light. Resident #49…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-31 · tag F0638 — isolated
    Assure that each resident’s assessment is updated at least once every 3 months.
    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 Assessments were completed timely. This affected one (Resident #53) of one reviewed for timely Resident Assessments. The facility census was 80. Findings include: Review of the medical record for Resident #53 revealed an admission date of 05/31/23 with diagnoses of mild cognitive impairment and chronic kidney disease. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #53 had impaired cognition. Further review revealed no additional quarterly or comprehensive assessments were completed after 06/05/23. Interview on 10/24/23 at 12:37 P.M. with MDS Coordinator #228 confirmed Resident #53 was due for a quarterly assessment on 09/05/23. MDS Coordinator #228 further stated she normally received reminders from the Regional Office when assessments were due and could not determine why the quarterly assessment for Resident #53 was not completed. Review of the guidance provided by 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 15 citations
  • Potential for harm · D2023-10-31 · 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 record review and staff interview, the facility failed to ensure an accurate Resident Assessment was completed for two (Residents #16 and #25) of two residents reviewed for accurate Resident Assessments. The facility census was 80. Findings include: 1. Review of the medical record for Resident #16 revealed an admission date of 02/22/17 with diagnoses of urinary tract infection and neuromuscular dysfunction of the bladder. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 had an indwelling urinary catheter. Review of the quarterly MDS assessment dated [DATE] revealed Resident #16 did not have an indwelling urinary catheter. Interview on 10/23/23 at 10:42 A.M. with Resident #16 revealed she had a urinary catheter. Observation at that time revealed catheter tubing and a covered catheter bag. Interview on 10/25/23 at 5:18 P.M. with MDS Coordinator #228 confirmed Resident #16 had a urinary catheter at the time of the MDS assessment completed 10/06/23 and the…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-31 · 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 medical record review, observation, and staff interview, the facility failed to ensure residents received sufficient assistance with Activities of Daily Living (ADL). This affected one (Resident #13) of three residents reviewed for ADL care. The facility census was 80. Findings include: Review of the medical record revealed Resident #13 was admitted on [DATE]. Diagnoses included Alzheimer's disease, cerebrovascular disease, type two diabetes mellitus, hyperlipidemia, hypothyroidism, essential hypertension, dyspnea, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. The resident required extensive one person assistance with personal hygiene. Review of the most recent care plan revealed Resident #13 required staff assistance to complete activities of daily living (ADL) tasks completely and safely. Interventions included to allow the resident sufficient time to complete all or part of a task, do not rush 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 · D2023-10-31 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    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 review of facility policy, the facility failed to include residents in activities that met their interests. This affected one (Resident #4) of one reviewed for activities. The facility census was 80. Findings include: Review of the medical record for Resident #4 revealed an admission date of 12/12/14 with diagnoses of Down's syndrome and functional quadriplegia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was rarely/never understood. Review of the comprehensive MDS assessment dated [DATE] for activity preferences revealed Resident #4 enjoyed listening to music and participating in religious activities or practices. Review of the Annual Life Enrichment assessment dated [DATE] revealed Resident #4 was rarely/never understood and family was not available for interview. Further review revealed Resident #4 enjoyed live entertainment, music, and it was somewhat important to him to participate in religious…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-31 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, and staff interview the facility failed to ensure residents were timely assessed for therapy services. This affected one (Resident #41) of one reviewed for mobility. The facility census was 80. Findings include: Review of the medical record revealed Resident #41 was admitted on [DATE]. Diagnoses included central cord syndrome at C4 level of cervical spinal cord, atrial fibrillation, atherosclerotic heart disease of native coronary artery without angina pectoris, chronic obstructive pulmonary disease, hypertensive heart disease with heart failure, hyperlipidemia, essential hypertension, and osteoarthritis. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required extensive one person assistance with dressing and personal hygiene and extensive two-person assistance with bed mobility, transfers, and toilet use. Review of range of motion documentation dated 07/23/23 to 10/23/23 revealed Resident #41…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-31 · 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 record review, observations, resident interview, staff interview, and review of facility policy, the facility failed to provide appropriate catheter care per standards of care to potentially prevent infection. This affected two (Residents #14 and #44) out of three reviewed for indwelling catheters. The current census is 80. Findings include: 1. Record review for Resident #44 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #44 included diabetes, sleep apnea, lymphedema, presence of unigenital implants, urinary tract infections, and neuromuscular dysfunction of bladder. Review of Resident #44's Minimum Data Set (MDS) dated [DATE] revealed the resident had intact cognition, was incontinent of bowel and bladder, and required extensive two-person assist with transfers. Further review of the MDS assessment revealed the resident had an indwelling catheter. Review of Resident #44's care plan dated 08/2023 revealed a focus for bowel and bladder includes a catheter for the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-31 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    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 facility's policy, record review, and staff interview, the facility failed to ensure the provider responded in a timely manner to all pharmacy recommendations for gradual dose reductions of medications. This affected two (Residents #25 and #44) of five reviewed for unnecessary medications. The current census is 80. Findings include: 1. Record review for Resident #44 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #44 include diabetes, sleep apnea, lymphedema, presence of urogenital implants, urinary tract infections, and neuromuscular dysfunction of bladder. Review of Resident #44's Minimum Data Set (MDS) dated [DATE] revealed the resident had intact cognition, was incontinent of bowel and bladder, and required extensive two-person assist with transfers. Further review of the MDS assessment revealed the resident had an indwelling catheter. Review of Resident #44's care plan dated 08/2023 revealed a focus for psychotropic drug use with interventions 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-31 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interviews, and review of facility policy, the facility failed ensure residents were free from unnecessary psychotic medication by failing to to ensure as needed psychotropic medications were limited to 14 days and by failing to ensure psychotropic medication were not administered in an excessive dose for Resident #40. In addition, the facility failed to ensure psychotropic medication were prescribed with appropriate diagnosis, appropriate dosage and with administration instructions including defined administration parameters for Resident #58. This affected two (#40 and #58) of five residents reviewed for unnecessary medication. The facility census was 80. Findings include: 1. Review of the medical record revealed Resident #40 was admitted on [DATE]. Diagnoses included Alzheimer's disease with late onset, type two diabetes mellitus, dementia with behavioral disturbance, hyperlipidemia, hypothyroidism, major depressive disorder recurrent severe with psychotic symptoms,…

    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 · D2023-10-31 · tag F0881 — failed to use antibiotics responsibly — isolated
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the facility's policy, and staff interview the facility failed to follow the protocols for the antibiotic stewardship. This affected one (Residents #44) of five residents reviewed for antibiotic stewardship. The current census is 80. Findings include: Record review for Resident #44 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #44 included diabetes, sleep apnea, lymphedema, presence of unigenital implants, urinary tract infections, and neuromuscular dysfunction of bladder. Review of Resident #44's Minimum Data Set (MDS) dated [DATE] revealed the resident had intact cognition, was incontinent of bowel and bladder, and was an extensive two-person assist with transfers. Further review of the MDS assessment revealed the resident had an indwelling catheter. Review of Resident #44's care plan dated 08/2023 revealed a focus for prophylactic antibiotic use related to recurrent urinary tract infections. Interventions included resident education…

    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 · Fcited before2021-07-30 · 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 record review, observation, staff interview, and review of the cleaning schedule, the facility failed to ensure the walk-in refrigerator was clean, failed to use safe food handling techniques when touching ready to eat meat with bare hands, and facility failed to distribute meals in a sanitary manner. This affected 11 (#10, #12, #17, #19, #20 #21, #22, #27, #28, #40, and #43) residents who received pureed or mechanically soft food, affected two residents (#11 an #54) and had the possibility to affect 18 residents who received lunch meals in their rooms, and affected all 64 residents who receive food from the kitchen. The facility identified two resident (Resident #31 and #49) who did not receive food from the kitchen. The facility census was 66. Findings include: 1. Observation on 07/26/21 at 9:28 A.M. revealed the walk-in kitchen refrigerator storage shelves with white fuzzy mold like substance. Interview on 07/26/21 at 9:36 A.M. with Dietary Manager #341 verified the white fuzzy mold like substance on the refrigerator storage shelves appeared to be mold. Dietary Manager…

    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 · D2021-07-30 · 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

    Based on observation, review of the medical record, staff interview, and review of the facility's policy, the facility failed to treat residents with dignity by hanging a sign with resident care needs on the wall near the resident's bed. This affected one (#21) of two residents reviewed for dignity. The facility census was 66. Findings include: Review of Resident #21's medical record revealed an admission date of 11/30/16. Diagnoses included dementia with behavioral disturbance, other intervertebral disc degeneration lumbar region, major depressive disorder, anxiety disorder, generalized muscle weakness, difficulty walking, and unspecified lack of coordination. Review of the Minimum Data Set (MDS) assessment, dated 07/06/21, revealed Resident #21 was severely cognitively impaired and required extensive assistance to total dependence with activities of daily living. Observation on 07/26/21 at 11:04 A.M. revealed a sign hanging on the wall near Resident #21's bed. The sign stated, For (Resident's name) transfers: Please use the steady with two assistance, must use gait belt. Please…

    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 · D2021-07-30 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, resident and staff interviews, and review of the facility's policy, the facility failed to honor a resident's choices for bedtime. This affected one (#3) of one resident reviewed for choices. The facility census was 66. Findings include: Review of Resident #3 medical record revealed an admission date of 09/25/19. Diagnoses included quadriplegia, central cord syndrome at C4 level of cervical spinal cord, post-traumatic stress disorder, major depressive disorder single episode, anxiety disorder,personality disorder unspecified, sleep apnea, restless legs syndrome, and history of unspecified fracture of T9-T10 vertebra subsequent encounter for fracture with routine healing. Review of the annual Minimum Data Set (MDS) assessment, dated 07/03/21, revealed the resident was cognitively intact. Resident was two-person extensive assistance for bed mobility and transfers. It was very important for Resident #3 to choose his own bedtime. Review of the Annual or Significant Change Life Enrichment Assessment, completed 07/14/21, revealed it was very important 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-07-30 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    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 the facility's policy, the facility failed to flush a bolus tube feed as physician ordered. This affected one (#31) of two residents reviewed for tube feeding. The facility identified three residents who receive tube feed. The facility census was 66. Findings include: Review of the medical record review for Resident #31 revealed an admission date of 05/03/17. Diagnoses included Parkinson's disease, pneumonia, dementia in other diseases classified elsewhere without behavioral disturbance, dysphagia oropharyngeal phase, hyperosmolality and hypernatremia, idiopathic paraplegia, dehydration, hyperlipidemia, and hypothyroidism. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/14/21, revealed the resident was rarely understood and the resident had a feeding tube. Review of the physician order, dated 01/31/21, revealed an order for enteral bolus feeding of 320 milliliter (ml.) five times a day at 5:00 A.M., 9:00 A.M., 1:00 P.M., 5:00 P.M., and 9:00 P.M. and to flush with 75 ml. before and after…

    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 · D2021-07-30 · 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, medical record review, staff interview, and review of the facility's policy, the facility failed to change oxygen supplies. This affected one (#5) of two residents reviewed for respiratory care. The facility identified 12 residents who receive respiratory care. The facility census was 66. Findings include: Review of the medical record review for Resident #5 revealed the resident was admitted on [DATE]. Diagnoses included chronic obstructive pulmonary disease with (acute) exacerbation and acute and chronic respiratory failure with hypoxia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/05/21, revealed the resident was cognitively intact. The resident received oxygen treatment. Review of the physician orders, dated 12/21/19, revealed to change the oxygen tubing monthly on the first day of the month. Observation on 07/26/21 at 10:49 A.M. of Resident #5 revealed the resident was sitting in a recliner chair with oxygen nasal cannula in place. Observation of the oxygen tubing…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-07-30 · 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

    Based on observation, staff interview, medical record review, and review of a drug manufacturer's administration instructions, the facility failed to administer medications without a significant medication error by not priming an insulin pen prior to administration. This affected one (#53) of three residents reviewed during medication administration. The facility identified 13 residents with orders for insulin. The facility census was 66. Findings include: Review of Resident #53's medical record revealed an admission date of 06/23/21. Diagnoses included diabetes mellitus type II. Review of the physician order, dated 07/26/21, revealed Resident #53 was ordered Lantus insulin 17 units subcutaneously (SQ) daily in the morning. Observation on 07/27/21 at 8:00 A.M. revealed Licensed Practical Nurse (LPN) #344 administering Resident #53's morning medications. Resident #53's scheduled Lantus insulin was not available in the medication cart so LPN #344 left to go retrieve it from the medication room. LPN #344 returned to the medication cart with Resident #53's Lantus insulin in the form 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 · D2021-07-30 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and policy review, the facility failed to properly store insulin. This affected two of three medication carts observed. This affected three residents (#32, #54 and #261). The facility identified 13 residents who receive insulin. Findings include: Observation on 07/28/21 at 2:20 P.M. of the 100 hall medication cart revealed an opened vial of Humalog insulin, with Resident #32's name, with an opened date of 06/22/21. A second vial of Humalog insulin with Resident #261's name was opened and undated. The observation was confirmed by Licensed Practical Nurse (LPN) #376. Observation on 07/28/21 at 2:44 P.M. of the 300 hall medication cart revealed an opened vial of Humalog insulin with the pharmacy label partially removed. Residents #54's name was written in ink on the box, dated 07/26/21. Registered Nurse (RN) #403 verified the missing pharmacy label. Review of the facility's policy titled Storage of Medications, dated 10/2019, revealed all medications, dispensed by the pharmacy, will be stored in the original container with the pharmacy label.…

    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.

Part of a chain

This home belongs to TRILOGY HEALTH SERVICES — 123 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 54.2-0.2 vs chain
Health inspection 3 of 53.5-0.5 vs chain
Staffing 3 of 53.3-0.3 vs chain
Quality measures 5 of 54.8+0.2 vs chain
The other 122 homes this chain runs (chain average 4.2★, per CMS)
1 of 5Heritage TheFindlay, OH 1 of 5The Oaks Rehabilitation and Healthcare CenterZanesville, OH 2 of 5Homewood Health CampusLebanon, IN 2 of 5Violet Springs Health CampusPickerington, OH 2 of 5Woodmont Health CampusBoonville, IN 3 of 5Cobblestone Crossings Health CampusTerre Haute, IN 3 of 5Creasy Springs Health CampusLafayette, IN 3 of 5Cumberland Pointe Health CampusWest Lafayette, IN 3 of 5Forest Park Health CampusRichmond, IN 3 of 5Franciscan Health Care CenterLouisville, KY 3 of 5Greenleaf Health CampusElkhart, IN 3 of 5River Terrace Health CampusMadison, IN 3 of 5Scenic Hills At The MonasteryFerdinand, IN 3 of 5Smiths Mill Health CampusNew Albany, OH 3 of 5Springhurst Health CampusGreenfield, IN 3 of 5Springs Of Richmond, TheRichmond, IN 3 of 5St Mary Healthcare CenterLafayette, IN 3 of 5Stonegate Health CampusLapeer, MI 3 of 5Sun Prairie Senior LivingSun Prairie, WI 3 of 5Taylor Springs Health CampusGahanna, OH 3 of 5The Willows at Fritz FarmLexington, KY 3 of 5The Willows at HamburgLexington, KY 3 of 5The Willows at HarrodsburgHarrodsburg, KY 3 of 5The Willows at SpringhurstLouisville, KY 3 of 5Villages At Oak Ridge, TheWashington, IN 3 of 5Waunakee Valley Senior LivingWaunakee, WI 3 of 5Wellbrooke Of CarmelCarmel, IN 4 of 5Arlington Place Health CampusIndianapolis, IN 4 of 5Ashford Place Health CampusShelbyville, IN 4 of 5Aspen Place Health CampusGreensburg, IN 4 of 5Avalon Springs Health CampusValparaiso, IN 4 of 5Bethany Pointe Health CampusAnderson, IN 4 of 5Blair Ridge Health CampusPeru, IN 4 of 5Bridgepointe Health CampusVincennes, IN 4 of 5Cedar Creek Health CampusLowell, IN 4 of 5Clearvista Lake Health CampusIndianapolis, IN 4 of 5Forest Springs Health CampusLouisville, KY 4 of 5Glen Oaks Health CampusNew Castle, IN 4 of 5Glen Ridge Health CampusLouisville, KY 4 of 5Meadows Of Delphos TheDelphos, OH

Showing 40 of 122; lowest-rated first.

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
CONTINENTAL MERGER SUB LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 10/01/2021
NORTHSTAR HEALTHCARE INCOME INCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 10/01/2021
NORTHSTAR HEALTHCARE INCOME OPERATING PARTNERSHIP LPOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 10/01/2021
TRILOGY HOLDINGS NT-HCI, LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 10/01/2021
KEYBANK NATIONAL ASSOCIATIONOrganization5% OR GREATER MORTGAGE INTERESTsince 12/15/2017
CORBIN, KATHYIndividualW-2 MANAGING EMPLOYEEsince 01/11/2011
FIGHTMASTER, LISAIndividualW-2 MANAGING EMPLOYEEsince 12/01/2015
BARNEY, LEIGHIndividualCORPORATE OFFICERsince 11/01/2019
BRYANT, WILLIAMIndividualCORPORATE OFFICERsince 01/05/2016
BUFFORD, RANDALLIndividualCORPORATE OFFICERsince 11/01/2019
CONNER, GREGORYIndividualCORPORATE OFFICERsince 06/03/2021
DAVIS, DAVIDIndividualCORPORATE OFFICERsince 08/21/2017
MEHAFFEY, TODDIndividualCORPORATE OFFICERsince 01/31/2022
PIETROWSKI, CRISTINAIndividualCORPORATE OFFICERsince 01/31/2022
PROSKY, DANNYIndividualCORPORATE OFFICERsince 12/01/2015
STREIFF, MATHIEUIndividualCORPORATE OFFICERsince 12/01/2015
TRILOGY MANAGEMENT SERVICES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 10/01/2021
SHERRY, JAMESIndividualOPERATIONAL/MANAGERIAL CONTROLsince 06/11/2012

6 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$11.6M
Net patient revenuemost recent cost report
+17.7%
Operating marginrevenue minus expenses
$1.4M
Related-party expense15% of expenses
Who pays — share of resident-days
Medicaid 37%Medicare 10%Other / private 53%

This home reported $1.4M paid to related parties — landlords or management companies under common ownership — equal to about 15% 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

$250per resident / day
operating cost
$7,610per month
≈ monthly operating cost
$304per 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 366423. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-01-30, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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