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Grand River Health & Rehab Center

1515 Brookstone Blvd, Painesville, OH 44077 · For profit - Corporation · 80 certified beds · (440) 357-6181 Medicare & Medicaid certified

Call the home — (440) 357-6181 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citations on record (F0602, F0606) — most recent Nov 20232 actual-harm citations$66,420 in federal fines1 Medicare payment denial
Insights

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

Worth asking about
  • it has abuse, neglect, or exploitation citations (F0602, F0606) — most recent Nov 2023
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (34) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $66,420 in federal fines (most recent 2025-05-12)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (2/5)
  • about 26% of its spending goes to commonly-owned related companies

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

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

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 4 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
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1506 Mentor Ave · (440) 354-5609 · Call to confirm hours
Pharmacy
1506 Mentor Ave · (440) 354-5609 · Call to confirm hours
Grocery
1475 Mentor Ave · (440) 354-2348 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
5544 E Heisley Rd · (440) 354-8369

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 3 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased2.5%5.3%15.4%better than state — see note marked double-dagger below the table
Long-stay residents who lose too much weight6.3%6.2%5.4%worse
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 symptoms35.0%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 injury0.9%3.2%3.3%better
Long-stay residents whose ability to walk worsened5.5%6.1%16.1%better than state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication20.7%25.5%18.9%typical
Long-stay residents given the seasonal flu vaccine96.6%94.5%95.3%typical
Long-stay residents with pressure ulcers7.7%3.4%4.7%worse
Long-stay residents with worsening bladder/bowel control22.8%21.4%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table5.4%8.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.7%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine60.0%75.6%79.4%worse
Short-stay residents rehospitalized after admission35.5%24.9%22.6%worse
Short-stay residents with an outpatient ER visit23.0%12.9%12.0%worse

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.

62.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 142 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

62.0%U.S. median 51.5%
Got home and stayed home
9.8%U.S. median 10.7%
Went back to hospital
47.6%U.S. median 56.6%
Met the expected recovery
0.32U.S. median 0.31
Therapy hours / resident / day
0.16hours / resident / day
Physical therapy
0.12hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 47.6% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 63 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 0.32 therapist hours per resident per day in 2026Q1 — more than 52% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 18% 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 SNF62.0%CMS range 54.1–70.951.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.8%CMS range 7.1–13.410.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge47.6%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 discharge58.7%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 discharge57.1%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 identified97.9%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 setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.1%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 worsened2.1%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 hospitalization6.8%CMS range 4.4–10.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.841.02Oct 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

0.60
RN hours/ resident / day
1.02
LPN hours/ resident / day
1.92
Aide hours/ resident / day
3.55
Total nurse hours/ resident / day
0.32
RN hoursweekends
46.0%
Total nursing turnover
41.7%
RN turnover

How full it usually is: this home is certified for 80 beds and averages 72.7 residents a day — about 91% occupied, or roughly 7 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 3.55 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.60 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.92 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.18 hrs/resident/day on weekends vs 3.69 on weekdays — 14% thinner on weekends. RN hours go from 0.71 to 0.32 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 46% 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

14
deficiencies at the latest standard inspection (2025-05-12)
4
at the previous standard inspection (2022-07-28)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

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

ABCDEFGHIJKL

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

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

  • Actual harm · G2025-05-12 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, medical record review, hospital record review, facility policy review, staff, and resident interviews, the facility failed to develop and implement a comprehensive, individualized, and effective pain management program for Resident #220 who was admitted with acute pain from unspecified fracture of upper and lower end of left tibia, and nondisplaced cervical fracture caused by a motor vehicle accident. Actual Harm occurred beginning on 04/25/25 when Resident #220 did not receive the ordered medication pain reliever Oxycodone five milligram immediate release tablet every four hours as needed. The medication was not administered until 04/26/25 at 2:26 P.M. During this time, Resident #220 had complaints of unrelieved pain making it hard to sleep, perform day-to-day activities, and sleep. This affected one resident (#220) of the four residents reviewed for pain management. The facility census was 66. Findings include: Review of Resident #220's medical record revealed an admission date of 04/25/25 at 5:47 P.M. Resident #220 had diagnoses of traumatic shock,…

    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
  • Actual harm · Gcited before2023-11-07 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, closed record review, facility policy review and interview the facility failed to ensure timely assessments were completed and adequate interventions were implemented to prevent the development of pressure ulcers for Resident #76. Actual Harm occurred on 08/26/23 when Resident #76, who was a paraplegic and required extensive assistance to total dependence from staff for activities of daily living (ADL) including bed mobility, toileting, and transfers was found to have an unstageable (full thickness tissue loss in which the actual depth of the ulcer was obscured by slough/ dead skin) pressure ulcer to his sacrum (area at the base of the spinal cord) and a deep tissue injury (an injury to the soft tissue under the skin due to pressure and was usually over a boney prominence) to his right buttock. There was no documented evidence adequate interventions and monitoring were in place to prevent the development of these wounds or to ensure the wounds were identified prior to being an unstageable…

    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 before2026-03-17 · 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 record review and interview, the facility failed to initiate wound care promptly upon identification of a pressure sore. This affected one resident (#72) of three residents reviewed for pressure sores. The facility census was 71. Findings include:Review of the medical record for Resident #72 revealed she was admitted [DATE] and had diagnoses including cellulitis, prediabetes, and pressure sores. A wound assessment done on 09/05/25 revealed she had an unstageable pressure sore (full-thickness tissue loss and covered by necrotic tissue) on the coccyx measuring two centimeters (cm) length by two cm width with light serous exudate (clear, thin, watery plasma). No specific wound care orders were initiated or documented as completed until 09/08/25 when triad wound cream was ordered to be applied to the coccyx twice daily. The first wound nurse practitioner assessment dated [DATE] identified the wound to measure 11.5 cm length by 11.2 cm width with moderate serosanguinous exudate (clear fluid with small…

    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 · Ecited before2025-05-12 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    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 reviews, interviews and review of the facility policy, the facility failed to ensure Resident #167 had accurate documentation related to the open areas to her posterior thighs and failed to ensure treatment instructions were given to the resident and her representative upon discharge. In addition, the facility failed to follow admission and readmission physician's orders for Resident #60. This affected resident (#167) of one resident reviewed for skin conditions, non-pressure related and one resident (#60) of two residents reviewed for change in condition. The facility census was 66. Findings include: 1. Review of Resident #167's medical record revealed an admission date of 03/11/25 with diagnoses including diabetes mellitus with ketoacidosis without coma, paroxysmal atrial fibrillation, influenza, acute respiratory failure with hypoxia. Resident #167 was discharged from the facility on 04/03/25. Review of Resident #167's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-05-12 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and policy review, the facility failed to store and label drugs according to manufacture guidelines. This affected seven residents (#57, #49, #27, #41, #38, #46, and #4) and had the potential to affect all residents receiving insulin. The facility identified 17 residents (#1, # 4, #10, #22, #27, #32, #33, #34, #38, #46, #49, #57, #219, #220, #221, #225) with orders for insulin. The facility's census was 66. Findings include: Observation of the medication cart on [DATE] at 10:03 A.M. identified Lispor Kwikpen opened for Resident #57. There were two Basaglar Kwikpens for Resident #49 opened and dated [DATE] and [DATE]. Resident # 27 had an opened Lantus Solostar Pen with no open date on the device or the bag it was in. Interview on [DATE] at the time of the observation with Licensed Practical Nurse (LPN) #258 and Minimum Data Set (MDS) Coordinator/LPN #268 verified the insulin pens were not dated and/or they were expired according to manufacturing standards. Observation of 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-05-12 · tag F0880 — failed to prevent and control infections — pattern
    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 record review, observation, staff interview and facility policy review, the facility failed to ensure infection control practices were being implemented for Transmission Based Precautions (TBP) for Resident #218 with Coronavirus Disease 19 (COVID-19). This affected one resident (#218) out of one resident reviewed for TBP. This had the potential to affect 12 residents (#2, #16, #24, #29, #34, #43, #60, #218, #220, #224, #227, #228) on Certified Nursing Assistant (CNA) #252's assignment. The facility failed to ensure Resident #226's indwelling Foley catheter drainage bag was not on the floor. This affected one resident (#226) of three residents reviewed for indwelling Foley catheters. The facility failed to ensure infection control was maintained during incontinence care for Resident #22. This affected one resident (#22) of three residents reviewed for incontinence care. In addition, the facility failed to properly clean a glucometer prior to checking a blood sugar for Resident #58 and failed to remove…

    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 before2025-05-12 · 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 observation, resident record review, staff interviews, and facility policy review, the facility failed to ensure residents were treated with dignity and respect. This affected three residents (#41, #217, and #226) of three residents reviewed for resident rights and dignity. The facility census was 66. Findings include: 1. Review of Resident #41''s medical records revealed an admission date of 09/11/21. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, obstructive and reflux uropathy, presence of urogenital implants and type two diabetes mellitus. Review of the physician orders for May 2025 revealed an order to provide a privacy cover for the indwelling urinary catheter drainage bag every shift. Review of the care plan revised 04/07/25 revealed Resident #41 had an indwelling urinary catheter. Interventions included ensuring Resident #41 had a privacy cover for the indwelling urinary catheter drainage bag. Observations on 04/28/25 at 10:30 A.M.…

    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 · D2025-05-12 · tag F0553 — failed to let residents help plan their care — isolated
    Allow resident to participate in the development and implementation of his or her person-centered plan of care.
    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 Resident #51's/Power of Attorney's (POA's) request to have her medication discontinued was completed timely. This affected one resident (#51) of one residents reviewed for choices. The facility census was 66. Findings include: Review of Resident #51's medical record revealed an initial admission date of 07/31/22 with diagnoses including multiple sclerosis (MS), obstructive and reflux uropathy, dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, and muscle weakness. Review of Resident #51's physician orders dated 02/12/25 revealed Avonex (interferon beta-1a) syringe kit 30 micrograms (mcg) per 0.5 milliliter (mL), one injection, intramuscular, once a day on Wednesdays at 12:30 P.M. Resident #51's Avonex was discontinued on 04/23/25. Review of Resident #51's progress notes dated 02/24/25 at 4:03 P.M. included Physician #277 was called regarding Resident #51's daughter request…

    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 before2025-05-12 · 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 record review, observation and interviews, the facility failed to ensure Resident #217 had a working toilet. This affected one resident (#217) of one residents reviewed for accommodation of needs. The facility census was 66. Findings include: Review of the medical record for Resident #217 revealed an admission date of 04/25/25. Diagnoses included type two diabetes mellitus (DM), pain right and left knee, anxiety, depression, long term use of anticoagulants, and overactive bladder. Review of the admission Minimum data Set (MDS) assessment dated [DATE] revealed it was in progress. Review of the admission assessment for bowel and bladder revealed Resident #217 was continent of bladder and bowel. Interview with Resident #217 on 04/28/25 at 11:31 A.M. revealed she did not have a handle on her toilet, and it didn't flush. Resident #217 reported it was like this on admission and not fixed. Resident #217 reported she knew it didn't work because staff had to empty the bedside commode into the toilet and dump…

    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 · D2025-05-12 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    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, record review, review of the fire department report and review of the facility policy, the facility failed to ensure Resident #167 had a safe discharge. The facility failed to ensure Resident #65 had an accurate and thorough assessment for a change in condition and transfer to the hospital. This affected two residents (#65 and #167) out of three residents reviewed for discharge. The facility census was 66. Findings include: 1. Review of Resident #167's medical record revealed an admission date of [DATE] with diagnoses including diabetes mellitus with ketoacidosis without coma, paroxysmal atrial fibrillation, influenza, acute respiratory failure with hypoxia. Resident #167 was discharged from the facility on [DATE]. Review of Resident #167's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #167 had severe cognitive impairment. Resident #167 required substantial to maximal assistance for toileting hygiene, personal hygiene, dressing, bathing and bed…

    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 · D2025-05-12 · 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, observations and interview, the facility failed to ensure an accurate assessment was completed for Resident #43. This affected one resident (#43) of 23 residents reviewed for assessments. The facility census was 66. Findings include: Review of Resident #43's clinical record revealed an admission date of 03/04/24 with diagnoses including unspecified atrial fibrillation, aphasia following cerebral infarction, unspecified osteoarthritis, and essential hypertension. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #43 revealed on section A she spoke English, and it was her preferred language. The facility answered no to the question if she needed or wanted an interpreter to communicate with a doctor of healthcare staff. Section B stated staff usually understood her. Section C on the assessment stated resident is rarely or never understood so staff assessment had to be performed regarding her cognition. The staff assessment for mental status revealed she had 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-12 · 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

    Based on record review, observations, interview and facility policy review, the facility failed to develop and implement a comprehensive care plan for Resident #43. This affected one resident (#43) of 23 residents reviewed for comprehensive care plans. The facility census was 66. Findings include: Review of Resident #43's clinical record revealed an admission date of 03/04/24 with the diagnoses of unspecified atrial fibrillation, aphasia following cerebral infarction, unspecified osteoarthritis, and essential hypertension. Observation of Resident #43 on 04/28/25 at 10:00A.M. revealed that she was unable to speak English. Her primary language was Italian which was verified by her daughter who has a room next to the resident. Interview on 04/28/25 at 10:25 A.M. with Certified nursing Assistant (CNA) #212 stated that there was a communication sheet that was pinned on the wall on the other side of the room where Resident #43 was unable to reach. CNA #212 stated that it was not left at the bedside because something would spill on it. CNA #212 stated that the family was the primary…

    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 22 citations
  • Potential for harm · D2025-05-12 · 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 observation, interview, record review, review of therapy recommendations and facility policy review, the facility failed to ensure Resident #51 received restorative services per therapy recommendations. This affected one resident (#51) out of three residents reviewed for therapy recommendations. The facility census was 66. Findings include: Review of Resident #51's medical record revealed an initial admission date of 07/31/22 with diagnoses including multiple sclerosis (MS), obstructive and reflux uropathy, dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, and muscle weakness. Review of Resident #51's care plan dated 06/12/24 included Resident #51 was at risk for deterioration in activities of daily living (ADL) related to diagnosis of MS. Resident #51 would continue to feed self-daily and participate in ADL as able daily. Interventions included physical therapy (PT) and occupational therapy (OT) for strengthening and endurance as indicated. Review of Resident…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of the facility policy, the facility failed to ensure Resident #51's care planned interventions for falls were implemented. This affected one resident (#51) out of three residents reviewed for falls. The facility census was 66. Findings include: Review of Resident #51's medical record revealed an initial admission date of 07/31/22 with diagnoses including multiple sclerosis (MS), obstructive and reflux uropathy, dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, and muscle weakness. Review of the facility incident log revealed Resident #51 had an unwitnessed fall on 03/25/25 at 5:32 A.M. and a fall on 04/25/25 at 10:26 A.M. Review of Resident #51's fall investigation included on 03/25/25 at 5:15 A.M. Resident #51 was noted lying on the floor at the side of the bed. The resident was assisted back to bed. Resident #51 had contracted bilateral lower extremities (BLE). The new intervention was to have body pillows 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-12 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, review of speech therapy (ST) evaluation and review of facility policy, the facility failed to ensure Resident #51's physician orders were followed and failed to ensure Resident #51's ST and care planned interventions were implemented for a significant weight loss. This affected one resident (#51) out of three residents reviewed for weight loss. The facility census was 66. Findings include: Review of Resident #51's medical record revealed an initial admission date of 07/31/22 with diagnoses including multiple sclerosis (MS), obstructive and reflux uropathy, dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, and muscle weakness. Review of Resident #51's physician orders dated 02/05/25 revealed ST evaluation, and treat as necessary. Review of Resident #51's physician orders dated 02/10/25 revealed to encourage Resident #51 to eat meals in the dining room and document refusals, every day. Review of Resident #51's Speech 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-12 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interviews, the facility failed to ensure a complete and accurate medical record for Resident #10. This affected one resident (#10) of three residents reviewed for activities of daily living (ADL). The facility census was 66. Findings include: Review of the medical record for Resident #10 revealed an admission date of 12/21/17 with diagnoses including functional quadriplegia, muscle weakness, contracture of hand, and dystonia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #10 was cognitively intact. The resident was dependent on staff for bathing. Interview on 04/29/25 at 8:02 A.M. with Resident #10 stated she didn't always get showers when she was supposed to. Review of the shower sheets from 04/26/25, 04/23/25, 04/19/25, 04/16/25, 04/12/25, 04/09/25, 04/05/25, 04/02/25, 03/29/25, 03/26/25, 03/22/25, 03/19/25, 03/15/25, 03/12/25, 03/08/25, 03/05/25, 03/01/25, and 02/26/25 revealed the shower sheets had not been completed…

    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 · D2024-08-05 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, review of Ohio Department of Health (ODH) Gateway and review of facility policy the facility failed to ensure an allegation of sexual abuse was reported not later than 24 hours to the state survey agency. This affected one resident (#74) out of six residents reviewed for abuse. The facility census was 72. Findings include: Review of the closed medical record for Resident #74 revealed an admission date of 01/26/23. She was sent to the hospital on [DATE] without returning. Her diagnoses included anxiety disorder, elevated white blood cell count, and aphasia (a language disorder that affects communication) following nontraumatic intracerebral hemorrhage. Review of the care plan dated 04/13/24 revealed Resident #74 refused medications and care at times. Interventions included assessing resident's resistance to care, encouraging resident to express fears, feelings and clarify misunderstandings, and reiterate the purpose and advantages of the treatment. Review of the quarterly…

    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 · Fcited before2023-12-01 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, record review, review of facility infection control policy, and review of Center of Disease Control and Prevention (CDC) donning guidelines revealed the facility failed to ensure staff donned proper fitting personal protective gowns to enter resident's rooms on droplet isolation precautions due to COVID-19. This affected 11 residents (#4, #5, #14, #19, #23, #26, #34, #39 #50, #54, and #74) on droplet isolation precautions for Covid-19 and had the potential to affect all 71 residents residing in the facility. Findings include: 1. Observation on initial tour of the facility on 11/28/23 from 11:05 A.M. to 11:43 A.M. revealed the following residents were on droplet isolation precaution: Residents #4 #5, #23, #26, #39, #54, and #74. They had a sign posted on their doors indicating they were on droplet isolation precautions and had white bins on the outside of their doors. The bins contained personal protective equipment (PPE) including short sleeved rain ponchos (a kind 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-01 · 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 interview, record review, and review of facility policy the facility failed to ensure there was adequate incontinence care products. This affected two residents (#40 and #66) out of three residents reviewed for proper incontinence care supplies. This had the potential to affect 59 residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10. #11, #12, #13, #14, #15, #16, #17, #19, #20, #21, #22, #24, #25, #27, #28, #30, #31, #32, #33, #33, #34, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #51, #52, #53, #54, #55, #58, #59, #60, #62, #63, #64, #65, #66, #68, and #69) that were identified by the facility as requiring incontinence care products. The facility census was 71. Findings include: 1. Review of the medical record for Resident #66 revealed an admission date of 11/21/22 with diagnoses including chronic kidney disease, heart failure, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66's cognitive status was not assessed. She…

    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 · D2023-11-07 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, record review, and review of facility policy the facility failed to ensure Resident #18's oxygen E cylinders (a portable three-foot-tall aluminum tank with compressed oxygen) were not misappropriated for other resident's use. This affected one resident (#18) out of three residents (#18, #35 and #45) reviewed for misappropriation of oxygen and had the potential to affect 14 residents (#7, #17, #18, #31, #34, #36, #37, #45, #46, #47, #51, #54, #63, and #74) with orders for oxygen. Findings include: Review of the medical record for Resident #18 revealed an admission date of 09/29/18 with diagnoses including chronic obstructive pulmonary disease (COPD), anxiety, and dementia. Review of the care plan dated 01/26/21 revealed Resident #18 was on oxygen therapy. Interventions included administering oxygen as ordered, assessing pulse oximetry as indicated, assess, monitor, and educate resident on signs of respiratory distress, and provide portable oxygen. Review of the Hospice Initial…

    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 · Dcited before2022-07-28 · 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 call lights were maintained within reach of residents. This affected one of four residents reviewed for environmental concerns (Resident #28). The census was 66. Findings include: 1. Observation on 07/25/22 at 9:41 A.M. revealed Resident #28 was in her room sitting in a chair equipped with a chair alarm. Her call light was in the bottom drawer of a dresser to her right, out of her immediate line of sight. It appeared to be out of her reach. Resident #28 was not interviewable. Interview with Registered Nurse #440 on 07/25/22 at 9:49 A.M. confirmed the above findings. She was familiar with Resident #28 and said the resident was capable of using her call light to request help. Following this interview, Registered Nurse #440 brought the padded call light (a call light which activates with light force anywhere on its surface instead of needing a pushed button) into reach of the resident. 2. Observation on 07/26/22 at 8:35 A.M. revealed…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-07-28 · 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 record review and interview the facility failed to notify the responsible party after Resident #18 was found on the floor. This affected one of three residents (#18, #47 and #48) reviewed for notification of change. Findings include: Review of the medical record for Resident #18 revealed an admission date of 01/28/22. Diagnoses included chronic diastolic heart failure, atrial fibrillation, cerebral infarction and osteoarthritis. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #18 had impaired cognition, required extensive assistance for bed mobility, and was totally dependent for transfers. Review of a head to toe assessment dated [DATE] revealed Resident #18 was found on the floor next to her bed, slumped over to her left side. The form indicated neither the family nor the physician were notified. Interview on 07/25/22 at 1:06 P.M. with Resident #18's daughter revealed she was not notified of the incident on 07/10/22 until a few days later. She believed she…

    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 before2022-07-28 · 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 and interview the facility failed to ensure staff contacted and communicated with hospice staff regarding Resident #18 being found on the floor. This affected one of three residents reviewed for hospice services. Findings include: Review of the medical record for Resident #18 revealed an admission date of 01/28/22. Diagnoses included chronic diastolic heart failure, atrial fibrillation, cerebral infarction and osteoarthritis. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #18 had impaired cognition, required extensive assistance for bed mobility, and was totally dependent for transfers. Review of the July 2022 physician orders revealed Resident #18 was under the care of hospice. Review of a head to toe assessment dated [DATE] revealed Resident #18 was found on the floor next to her bed, slumped over to her left side. The form indicated neither the family nor the physician were notified. There was no documentation related to notification of hospice.…

    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 before2022-07-28 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to administer medications with an error rate of under 5.0 percent. This affected two (Resident #8 and #42) of six (Resident #6, #14, #49, #8, #20, and #42) residents observed for medication administration. The total census was 66. Findings include: 1. Observation of medication administration for Resident #8 by Licensed Practical Nurse (LPN) #462 on [DATE] at 7:42 A.M. revealed the nurse drew the ordered omeprazole (a gastric acid reducer) from a pill card with a labeled expiration date of [DATE] and placed it in the cup with other medications to be administered. The surveyor confirmed the above finding with LPN #462 at the time of the observation. Following surveyor intervention, LPN #301 discarded the omeprazole and drew a new dose from a container which was not expired. 2. Observation of medication administration for Resident #42 by LPN #425 on [DATE] at 8:23 A.M. revealed one of the medications was one-half pill of metoprolol 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2019-08-07 · tag F0606 — failed to not employ staff found guilty of abuse — widespread
    Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and staff interview the facility failed to check all potential new hires against the State nurse aide registry (NAR) to ensure no employee had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property. This affected 14 Licensed Practical Nurses (LPNs), three Registered Nurses (RNs), three housekeeping staff, one Laundry staff, eight dietary staff and two Administrative staff whose personnel files were reviewed and had the potential to affect all 70 residents residing in the facility. Findings include: Review of a document titled Nurse Aide Roster, dated 08/07/19 revealed the record reflected 22 State tested nursing assistants currently employed at the facility. There were no other employees listed on the Nurse Aide Roster. Review of a document titled Employee Listing, dated 08/07/19 revealed the record reflected 14 Licensed Practical Nurses (LPNs), three Registered Nurses (RNs), three housekeeping staff, one Laundry staff, eight dietary staff and two…

    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 · Dcited before2019-08-07 · 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 observation, record review and interview the facility failed to provide care in a dignified manner for Resident #75 related to insulin medication administration and for Resident #42 related to personal/incontinence care. This affected one resident (#75) of three residents observed for insulin administration and one resident (#42) of two residents reviewed for dignity. Findings include: 1. Review of Resident #75's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including type two diabetes muscle weakness and heart failure. Review of Resident #75's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderate cognitive impairment. Review of Resident #75's physician's orders revealed an order dated 12/21/17 to administer Novolog five units subcutaneously before meals for diabetes and hold if the resident's blood sugar was less than 125. Observation on 08/04/19 at 11:59 A.M. with Registered Nurse (RN) #801 revealed the nurse turned 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 · D2019-08-07 · 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 observation, record review, and interview the facility failed to ensure Resident #4's care plan was revised to reflect oxygen titration and failed to ensure Resident #42's care plan was revised to reflect toileting behaviors. This affected two residents (#4 and #42) of five residents reviewed for care planning. Findings include: 1. Review of Resident #4's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including heart failure, acute respiratory failure, and hypertension. Review of the physician's orders dated 04/05/19 indicated Resident #4 was to be weaned off oxygen if tolerated and to keep her pulse oximetry above 92 percent every shift. An additional order dated 02/02/19 indicated oxygen at one liter per minute via nasal cannula to titrate for a pulse oximetry of 92 percent. Review of a physician order dated 02/17/19 indicated to change any oxygen tubing weekly and as needed on night shift on Sundays for oxygen care. Review of monthly nursing note dated…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-08-07 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure Resident #23's wound care was completed as ordered in the physician orders and failed to ensure treatment orders were documented accurately for the resident. This affected one resident (Resident #23) of one resident reviewed for non-pressure related skin conditions. Findings include: Review of Resident #23's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including essential hypertension, muscle weakness and altered mental status. Review of Resident #23's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #23's physician's orders revealed an order dated 07/30/19 to cleanse the wound with normal saline, pat dry, apply Vaseline with a Q-tip to the wound, cover with a non-adherent dressing and secure with paper tape every day shift for wound care for four weeks. Review of Resident #23's medication administration record (MAR)…

    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 before2019-08-07 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure Resident #130's right buttock pressure ulcer dressing was completed as ordered by the physician. This affected one resident (#130) of two residents reviewed for pressure ulcers. Findings include: Review of Resident #130's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including essential hypertension, weakness and diabetes type two. Review of Resident #130's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #130's physician orders revealed an order dated 07/31/19 to cleanse area to the buttocks with normal saline, pat dry, apply zinc oxide and cover with a foam dressing every night shift for skin care. Review of Resident #130's biweekly skin observation form, dated 08/01/19 revealed the resident had a right gluteal fold pressure ulcer with an open area to the lower portion. Review of Resident #130's medication…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-08-07 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure urinary catheter drainage collection bags were maintained in a clean, sanitary manner and off the floor to prevent the risk of developing a urinary tract infection. This affected two residents (#283 and #52) of seven residents identified to have urinary catheters. Findings include: 1. Record review revealed Resident #52 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, sepsis and urinary tract infection. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 06/28/19 revealed Resident #52 required total dependence of two staff for all activities of daily living (ADL) and had a urinary catheter. Resident #52 was assessed to be severe cognitively impaired. Review of laboratory testing results, dated 08/04/19 revealed the resident's urine was positive for the bacteria Pseudomonas aeruginosa and Escherichia coli extended-spectrum beta-lactamases (ESBL) resulting in the physician…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-08-07 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to maintain a medication error rate of less than 5% (percent). The medication error rate was calculated to be 11.11% and included three medication errors of 27 medication administration opportunities. This affected two residents (#16 and #75) of six residents observed for medication administration. Findings include: 1. Review of Resident #16's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including fibromyalgia, type two diabetes mellitus without complications and muscle weakness. Review of Resident #16's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #16's physician's orders revealed an order, dated 07/26/19 for Humulin N KwikPen (long acting insulin) inject 46 units subcutaneously in the afternoon for routine monitoring and an order dated 02/26/19 for Novolog (short acting insulin) inject as per sliding scale if 0 to 100 give…

    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 before2019-08-07 · 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, record review and interview the facility failed to maintain adequate infection control practices to prevent the spread of infection during medication administration for Resident #16 and Resident #75 and during wound care for Resident #51. This affected two residents (#16 and #75) of six residents observed for medication administration and one resident (#51) of three residents reviewed for wound care. Findings include: 1. Review of Resident #16's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including fibromyalgia, type two diabetes mellitus without complications and muscle weakness. Review of Resident #16's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #16's physician's orders revealed an order dated 07/26/19 for Humulin N KwikPen inject 46 units subcutaneously in the afternoon for routine monitoring and an order dated 02/26/19 for Novolog inject as per sliding scale if 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2024-09-18 · 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

    Based on record review, interviews with residents and staff and observations the facility failed to follow the menu as planned and posted. This affected 73 of 75 resident in the facility as Resident #9 and Resident #58 received no food by mouth. The census was 75. Findings Include: Observation on 09/17/24 at 12:20 P.M. of the test tray revealed beef stew over mashed potatoes, an eggroll and jello. Interviews and observations on 09/17/24 at 12:25 P.M. with Resident #8 and Resident #26 revealed Resident #8 had beef stew over mashed potatoes and Resident #26 had beef stew over rice. Both had egg rolls and jello. Resident #8 revealed they often do not get what was stated on the menu. Resident #26 agreed. Interview on 09/17/24 at 1:00 P.M. with the Food Service Director revealed she was using up stock before the facility switched food service companies. She stated she tried to keep it as close to the meal as possible. She verified she did not post or notify the residents beforehand. Review of the menu and the meal ticket for Resident #8 for 09/17/24 revealed it should have been beef…

    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 plan of correction
  • No harm found · C2019-08-07 · tag F0838 — failed to assess facility resources and resident needs — widespread
    Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and staff interview the facility failed to ensure current contracted Hospice service providers were listed on the Facility Assessment. This had the potential to affect all 70 residents residing in the facility. Findings include: An interview was conducted on 08/07/19 at 11:34 A.M. with the Director of Nursing who revealed there were two local Hospice providers contracted with the facility to provide services to those residents in need of Hospice services: Hospice provider #1 and Hospice provider #2. Review of the two agreements for services revealed an agreement with Hospice provider #1 dated 10/12/15 and an agreement with Hospice provider #2 dated 01/01/19. Review of the Facility Assessment, with a review date of 07/16/19 revealed the assessment did not list the contracts for the provision of services by Hospice Provider #1 or #2. The document did list a Hospice provider no longer providing services to residents in the facility. On 08/07/19 at 11:44 A.M. interview with the Director of Nursing verified the current Facility Assessment was not updated to include…

    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

“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

$66,420 in federal fines across 1 penalty. 1 Medicare payment denial on record.

  • $66,420 — penalty dated 2025-05-12
  • Medicare payment denial — starting 2023-12-05 for 4 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to SABER HEALTHCARE GROUP — 126 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 2 of 52.9-0.9 vs chain
Health inspection 2 of 52.6-0.6 vs chain
Staffing 2 of 52.2-0.2 vs chain
Quality measures 4 of 54.0≈ chain avg
The other 125 homes this chain runs (chain average 2.9★, per CMS)
1 of 5Autumn Care of MarshvilleMarshville, NC 1 of 5Autumn Care of Myrtle GroveWilmington, NC 1 of 5Autumn Care of WaynesvilleWaynesville, NC 1 of 5Brunswick Health & Rehab CenterAsh, NC 1 of 5Bryn Mawr Extended Care CenterBryn Mawr, PA 1 of 5Caring Heights Community Care & Rehab CtrCoraopolis, PA 1 of 5Colonial Health & Rehab Center, LLCVirginia Beach, VA 1 of 5Currituck Health & Rehab CenterBarco, NC 1 of 5Davidson Health & Rehab CenterLexington, NC 1 of 5Edison Manor Nursing & Rehabilitation CenterNew Castle, PA 1 of 5Gastonia Health & Rehab CenterGastonia, NC 1 of 5Greene Health & Rehab CenterGreensburg, PA 1 of 5Grey Stone Health And Rehabilitation CenterFort Wayne, IN 1 of 5Harmar Village Health & Rehab CenterCheswick, PA 1 of 5Highland Pointe Health & Rehab CenterHighland Heights, OH 1 of 5Hilltop Heights Health & Rehab CenterJohnstown, PA 1 of 5Maple Heights Health & Rehab Center, LLCEbensburg, PA 1 of 5Midtown Oaks Health & Rehab CenterAltoona, PA 1 of 5Mountain City Nursing & Rehabilitation CenterHazleton, PA 1 of 5Providence Health & Rehab CenterBeaver Falls, PA 1 of 5River's Bend Health & Rehab CenterHarrisburg, PA 1 of 5Riverside Health & Rehab CenterMcKeesport, PA 1 of 5South Boston Health & Rehab CenterSouth Boston, VA 1 of 5Tallmadge Health & Rehab CenterTallmadge, OH 1 of 5University Manor Health & RehaCleveland, OH 1 of 5Village Care of KingKing, NC 1 of 5Woodhaven Health & Rehab CenterMonroeville, PA 1 of 5Woodlands Health And Rehab CenterRavenna, OH 2 of 5Aurora Manor Special Care CentAurora, OH 2 of 5Autumn Care Of MadisonMadison, VA 2 of 5Autumn Care Of MechanicsvilleMechanicsville, VA 2 of 5Autumn Care Of SuffolkSuffolk, VA 2 of 5Autumn Care of CorneliusCornelius, NC 2 of 5Autumn Care of RaefordRaeford, NC 2 of 5Autumn Care of SaludaSaluda, NC 2 of 5Autumn Care of ShallotteShallotte, NC 2 of 5Azalea Health & Rehab CenterWilmington, NC 2 of 5Bath Manor Special Care CentreAkron, OH 2 of 5Berea Health & Rehab CenterFredericksburg, VA 2 of 5Broad Mountain Health And Rehabilitation CenterFrackville, PA

Showing 40 of 125; 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 / managerTypeRoleSince
BENJAMIN N. VOLPE FAMILY DYNASTY TRUST (DATED DECEMBER 29, 2020)OrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 01/01/2023
SABER HEALTHCARE HOLDINGS LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 01/01/2020
NICOLUZAKIS, GREGORYIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; ADP OF THE SNFsince 03/01/2019
VOLPE, BENJAMINIndividualCORPORATE DIRECTOR; CORPORATE OFFICER; ADP OF THE SNFsince 03/01/2019
WEISBERG, WILLIAMIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 03/01/2019
SABER GOVERNANCE LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/01/2019
SHG MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/01/2019
CEKANSKI, CYNTHIAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/25/2021
THUR, MARIEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/14/2021
BNV DYNASTY LLCOrganizationADP OF THE SNFsince 01/01/2023
CITRIN COOPERMAN ADVISORS LLCOrganizationADP OF THE SNFsince 09/01/2012
DECANTED WILLIAM I. WEISBERG FAMILY DYNASTY TRUST (DATED SEPT 30, 2020OrganizationADP OF THE SNFsince 01/01/2023
SHAMROCK RE GROUP, LLCOrganizationADP OF THE SNFsince 10/29/2017
TCF NATIONAL BANKOrganizationADP OF THE SNFsince 04/01/2024
WIW DYNASTY LLCOrganizationADP OF THE SNFsince 01/01/2023
PARMAR, HARBHAJANIndividualADP OF THE SNFsince 01/09/2018

CMS files one row per role, so the 26 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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

Follow the money — this home’s finances

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

$8.5M
Net patient revenuemost recent cost report
+10.7%
Operating marginrevenue minus expenses
$2.0M
Related-party expense26% of expenses
Who pays — share of resident-days
Medicaid 10%Medicare 8%Other / private 82%

This home reported $2.0M paid to related parties — landlords or management companies under common ownership — equal to about 26% 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

$301per resident / day
operating cost
$9,147per month
≈ monthly operating cost
$337per 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 365492. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-12, 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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