Pleasant Lake Villa
7260 Ridge Rd, Parma, OH 44129 · For profit - Corporation · 209 certified beds · (440) 842-2273 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (2/5)
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
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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 5 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 9.5% | 5.3% | 15.4% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 6.0% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.3% | 0.2% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.2% | 0.4% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 18.9% | 30.1% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.0% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 12.2% | 6.1% | 16.1% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 17.3% | 25.5% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 87.4% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.9% | 3.4% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 24.3% | 21.4% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 7.6% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.7% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 78.4% | 75.6% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 25.6% | 24.9% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 9.3% | 12.9% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.63 | 1.73 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.26 | 1.80 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
53.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 187 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 54.6% 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 108 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 0.29 therapist hours per resident per day in 2026Q1 — more than 44% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 23% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 53.5%CMS range 45.7–60.4 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.6%CMS range 7.4–13.6 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 54.6% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 57.4% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 40.7% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 96.6% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 3.7% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.7%CMS range 4.7–11.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.91 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 209 beds and averages 176.9 residents a day — about 85% occupied, or roughly 32 beds typically open. It usually has some room. 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 3.89 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.53 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.20 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 3.31 hrs/resident/day on weekends vs 4.12 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.59 to 0.38 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 47% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
26 citations, most serious first. The 11 most serious are shown; the remaining 15 are one tap away and print in full.
- Actual harm · G2019-11-21 · tag F0697 — failed to manage pain — isolatedProvide 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, record review and interview, the facility failed to implement a comprehensive and individualized pain management program for Resident #243 to treat the resident's gout. Actual harm occurred when Resident #243 experienced extreme pain, moaning and yelling out due to pain in toes related to a medical diagnosis of gout with a lack of intervention and/or administration of effective pain medication between 11/18/19 at 8:30 A.M. and 11/19/19 at 8:00 P.M. This affected one resident (#243) of three residents reviewed for pain. Findings include: Resident #243 was admitted to this facility on 10/31/19. On 11/06/19 the resident was sent out to the hospital for mental status change. He was readmitted to this facility on 11/13/19. His admitting diagnoses included pneumonia, chronic gout, chronic kidney disease, type II diabetes and enterocolitis due to clostridium difficile. On 11/18/19 at 8:30 A.M. the resident's significant other approached this surveyor stating that she needed to get the doctor to come and look at her husband. She stated he was in terrible pain and no…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2026-06-02 · tag F0804 — failed to serve food at safe, palatable temperature — widespreadEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of the food committee minutes, observation, interviews, and review of the ServSafe guidelines, the facility failed to ensure that residents received food at palatable temperatures. This deficient practice had the potential to affect all residents except those who received nothing by mouth, residents (#69, #110, and #207). The facility census was 170.Findings include:Review of the Food Committee Minutes for April 2026, residents (not identified) stated the food was not served as hot as the residents would like. Resident interviews conducted on 05/26/26 from 10:54 A.M. to 11:06 A.M. revealed that Residents #97 and #178 reported the food was cold.Review of the lunch menu for 05/28/26 showed items including honey baked ham, baked potato, key west vegetable blend, biscuit, sherbet, coffee or tea, and 2% milk.During an observation on 05/28/26 at 1:26 P.M., a sample test tray evaluated with the Dietary Manager (DM) #431 and Regional Director of Food Services (RFSD) #805 showed the following temperatures: baked potato at 146 degrees Fahrenheit (F), key west vegetable blend…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-06-02 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and review of the facility policy and procedure, the facility failed to ensure a clean and sanitary resident environment affecting 44 residents (#4, #8, #9, #11, #12, #13, #18, #19, #26, #29, #32, #33, #41, #45, #48, #50, #57, #58, #65, #76, #79, #102, #104, #109, #110, #114, #127, #133, #136, #141, #146, #147, #155, #158, #160, #171, #175, #178, #182, #188, #190, #192, #201, and #205) of 44 residents that resided on the Rosewood unit and had the potential to affect all 170 residents residing in the facility. Findings include: 1. During an interview on 05/26/26 at 10:32 A.M., Resident #32 reported that housekeeping did not routinely pick up trash or sweep and mop the floors. Observation at that time revealed crumbs and stains between, under, and behind both beds; under the heater; along the wall under the window; and between the dressers and the television. Dried stains were also noted on the heater. On 05/28/26 at 2:40 P.M., the Housekeeping Supervisor (HSKS #416) stated residents' rooms and common areas were to be cleaned daily. At that time, the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-02 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 Resident #233's medications were administered as ordered by the physician. This finding affected one resident (#233) of four residents reviewed for medication administration. The facility census was 170. Findings include:Review of Resident #233's medical record revealed the resident was admitted on [DATE] and discharged home on [DATE] with diagnoses including type one diabetes, anxiety disorder and depression.Review of Resident #233's physician orders revealed an order dated 03/31/26 (discontinued 05/09/26) for amitriptyline (used to treat depression, nerve pain, prevent migraines and an off-label used to treat insomnia, anxiety and other conditions) 100 milligrams (mg) give one tablet by mouth at bedtime for depression (due at 9:00 P.M.).Review of Resident #233's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition.Review of Resident #233's Psychotropic Medications Care Plan 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.
- Potential for harm · D2026-06-02 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interviews, and facility policy review, the facility failed to ensure that indwelling urinary catheter care was completed every shift as ordered and as required by facility policy, resulting in significant accumulation of smegma (body secretion made of oils, sweat, and dead skin cells) and increased risk of infection for one resident (#56) of three reviewed for catheter use. The facility census was 170.Findings include:Review of Resident #56 medical record revealed an admission date of 04/17/26 with multiple orthopedic injuries and a diagnosis of neuromuscular bladder dysfunction.Review of care plan for Resident #56 dated 04/20/26 revealed goals and interventions for risk of infection related to indwelling urinary catheter. Interventions included: assessing the resident for pain/discomfort; checking catheter for patency; enhanced barrier precautions; flushing catheter as needed; use catheter securement device; monitor for signs and symptoms of urinary tract infection; use…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-02 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review, the facility failed to ensure Resident #217's controlled medications were appropriately monitored and tracked by the facility. This finding affected one resident (#217) of four residents reviewed for medication administration. The facility census was 170. Findings include:Review of Resident #217's medical record revealed the resident was admitted on [DATE] and discharged on 06/13/25 with diagnoses including dementia, atrial fibrillation and anxiety disorder.Review of Resident #217's discharge Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment.Review of Resident #217's progress note dated 06/07/25 at 9:58 P.M. revealed two nurses placed calls to the pharmacy regarding the lacosamide anti-seizure (controlled medication) and narcotic pain medication (controlled medication). The pharmacist stated the medications were shipped at 7:00 P.M. and would be in. The family supplied the medications since…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-02 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record reviews, observations, interviews and facility policy review, the facility failed to ensure enhanced barrier precautions (EBP) were maintained per order. This affected two residents (#176, #207) out of four residents reviewed for isolation precautions. The facility census was 170.Findings include:1. Record review of Resident #207 revealed an admission date of 08/15/19 with diagnoses of Parkinson's Disease, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dysphagia, chronic obstructive pulmonary disease, contracture of hand, history of falling, hyperlipidemia and hypertension, presence of gastrostomy tube.Review of the physician's orders initiated on 03/26/26, revealed an order for EBP for high contact resident care including dressing, bathing, showering, transfers, hygiene care, changing linens, assisting with toileting, dressing changes, and care of any device (central line, tube feeding, and catheter) to reduce chance of spreading infection.Review of the care plan revised on 05/12/26 revealed interventions for EBP related…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-03-03 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and review of the facility's Coronavirus (COVID-19) policy, the facility failed to ensure personal protective equipment (PPE) was donned correctly for Resident #193, who was on droplet precautions to potentially prevent the spread of COVID-19 infections. This had the potential to affect 29 residents (Residents #165, #166, #167, #168, #169, #170, #171, #172, #173, #174, #175, #176, #177, #178, #179, #180, #181, #182, #183, #184, #185, #186, #187, #188, #189, #190, #191, #192, and #193) who resided on the Sandalwood unit. The facility census was 189. Findings include: Review of the medical record for Resident #193 revealed an admission date of 10/09/24 with diagnoses including kidney transplant, type one diabetes mellitus with chronic diabetic kidney disease, pressure ulcer of the left heel, pressure ulcer to the right heel, and history of urinary tract infections. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-13 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure Resident #135's nails were clean, and her chin was free of hair. This affected one resident (Resident #135) out of three residents (Residents #51, #135, and #187) reviewed for activities of daily living (ADLs). The facility census was 158. Findings include: Review of the medical record for Resident #135 revealed an admission date of 07/30/24 with diagnoses including diabetes mellitus, Alzheimer's disease, and anxiety disorder. Review of the Care Plan dated 04/14/22 revealed Resident #135 had a self-care deficit related to cognition and generalized weakness. Interventions included nail care as needed. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 08/06/24, revealed Resident #135 had moderately impaired cognition and required substantial/maximal assistance with ADLs. Observation and interview on 09/14/24 at 9:40 A.M. with Resident #135 revealed she was lying in bed; her fingernails were long and dirty and she had hairs growing on her chin. Resident #135 stated that she liked the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-06-06 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review revealed the facility failed to ensure multiple dose medications were dated when opened. This affected five residents (#39, #54, #81, #88 and #285) of 15 residents reviewed with insulin pens and two medication carts (Rosewood back and Oakwood front) of five medication carts reviewed. The facility census was 181. Findings Included: 1. Review of the medical record revealed Resident #285 was admitted to the facility on [DATE] with a diagnosis of type II diabetes. Review of the physician orders for June 2024 revealed an order for Insulin Glargine (long-acting insulin)100 unit/milliliter (ml) solution pen-injector. Observation on 06/06/24 at 10:01 A.M. of Oakwood front medication cart revealed Resident #285's insulin Glargine pen was dispensed on 04/25/24 and not dated to indicate when it was opened. Interview on 06/06/24 at 10:05 A.M. with Registered Nurse (RN) #995 verified Resident #285's insulin was dated when it was opened, and the 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.
- Potential for harm · D2024-06-06 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review the facility failed to ensure recommended guidelines were followed for changing disposable respiratory equipment for Residents #12, #15, and #83. This affected three residents (#12, #15, and #83) of six residents reviewed for respiratory care. The facility census was 181. Finding include: 1. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including pneumonia, epilepsy, heart failure, and chronic kidney disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had short-term and long-term memory problems and used oxygen daily. Review of Resident #12's physician's orders revealed an order dated 05/14/24 to change the oxygen tubing and clean the filter weekly per facility policy and change the aerosol tubing and setup and clean the filter weekly per facility policy. Review of the medication administration record (MAR) for May 2024 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.
Show the remaining 15 citations
- Potential for harm · Dcited before2024-04-03 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 interview and record review the facility failed to ensure wound treatments were completed as ordered. This affected one of three residents (Resident #152) reviewed for wound treatments. The facility census was 171. Findings Included: Review of the medical record for Resident #152 revealed an admission date of 09/06/22. Diagnoses included but were not limited to diabetes mellitus, dependence on renal dialysis, depression, pulmonary hypertension, absence of right leg below the knee, and calciphylaxis (calcium accumulates in small blood vessels of the fat and skin tissues). Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/10/24, revealed Resident #152 had intact cognition and was dependent or required maximal assistance for activities of daily living. Review of the treatment orders for April 2024 revealed an order to cleanse skin tear to right elbow once daily with normal saline, apply four by four and border gauze dressing daily, every day shift for wound care. Review of the 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.
- Potential for harm · Dcited before2024-04-03 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review and interview the facility failed to ensure Resident #152 was not administered expired medication (budesonide) and the medication was available for administration. This affected one of three residents (Resident #152) reviewed for medication administration. The facility census was 171. Findings Included: Review of the medical record for Resident #152 revealed an admission date of 09/06/22. Diagnoses included but were not limited to eosinophilic esophagitis (an allergic inflammatory condition of the esophagus), diabetes mellitus, and dependence on renal dialysis. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/10/24, revealed Resident #152 had intact cognition. Review of the physician orders for February 2024 revealed orders for budesonide liquid 10 milliliters (ml) by mouth (corticosteroid, gastrointestinal) one hour before meals for eosinophilic esophagitis. Started on 02/11/24 and discontinued on 03/29/24. Review of the February and March 2024 medication administration record (MAR) revealed the budesonide liquid was not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-03 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review and interview the facility failed to ensure Resident #152 received an anticoagulant medication to prevent the formation of blood clots as ordered. This affected one of three residents (Resident #152) reviewed for medication administration. The facility census was 171. Findings Included: Review of the medical record for Resident #152 revealed an admission date of 09/06/22. Diagnoses included but were not limited to diabetes mellitus, dependence on renal dialysis, pulmonary hypertension, absence of right leg below the knee, and calciphylaxis (calcium accumulates in small blood vessels of the fat and skin tissues. Calciphylaxis causes blood clots, painful skin ulcers and may cause serious infections that can lead to death.) Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/10/24, revealed Resident #152 had intact cognition. Review of the physician orders for February 2024 revealed orders for apixaban (anticoagulant) 2.5 milligrams (mg) tablet by mouth two times a day for atrial fibrillation. Review of the February and March 2024…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-11-08 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, review of the facility policy and review of the Centers for Disease Control (CDC) and Prevention guidelines, the facility failed to maintain an adequate infection control program to prevent the spread of infection. The facility failed to ensure staff donned appropriate personal protective equipment (PPE) prior to entering the room of and providing wound care to Resident #156 who had tested positive for Carbapenem-resistant Acinetobacter baumannii (CRAB). Furthermore, the facility failed to ensure Resident #155, who tested positive for CRAB washed his hands before leaving his room. This affected two sampled residents (#156 and #155) who tested positive for CRAB and had the potential to affect 42 additional residents (#1, #4, #10, #12, #26, #33, #34, #40, #45, #46, #54, #55, #56, #59, #60, #67, #68, #74, #80, #83, #89, #90, #93, #97, #98, #100, #102, #106, #109, #110, #112, #115, #116, #119, #121, #129, #137, #148, #150, #159, #160, #170) residing on the unit…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-08 · tag F0622 — isolatedNot transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
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 the facility policy, the facility failed to ensure Resident #172 and his Responsible Party were given a transfer notice when Resident #172 was transported from the facility via Emergency Medical Services to the local hospital for evaluation. This affected one resident (Resident #172) out of three residents reviewed for transfers and discharges. The facility census was 170. Findings include: Review of Resident #172's medical record revealed an admission date of 11/01/23 and diagnoses included unspecified dementia with agitation, restlessness and agitation, and type two diabetes mellitus. Resident #172 was discharged from the facility on 11/03/23. Review of Resident #172's admission Assessment and Baseline Care Plans dated 11/01/23 at 6:44 P.M. included Resident #172 had cognitive impairment with poor decision making skills and had a diagnosis of dementia. Resident #172 was alert, quiet and cooperative. Resident #172 could ambulate independently and did not have a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-08 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and review of the facility policy the facility failed to ensure Resident #172 and his Responsible Party were given a bed hold notice and transfer notice when Resident #172 was transported from the facility via Emergency Medical Services to the local hospital for evaluation. This affected one resident (Resident #172) out of three residents reviewed for transfers and discharges. The facility census was 170. Findings include: Review of Resident #172's medical record revealed an admission date of 11/01/23 and diagnoses included unspecified dementia with agitation, restlessness and agitation, and type two diabetes mellitus. Resident #172 was discharged from the facility on 11/03/23. Review of Resident #172's admission Assessment and Baseline Care Plans dated 11/01/23 at 6:44 P.M. included Resident #172 had cognitive impairment with poor decision making skills and had a diagnosis of dementia. Resident #172 was alert, quiet and cooperative. Resident #172 could ambulate independently…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-04-27 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and staff interview the facility failed to ensure a clean and well maintained environment. This affected 41 of 167 facility residents, Residents #15, #19, #22, #26, #35, #37, #38, #40, #47, #52, #59, #63, #69,#72, #73 #78, #79, #84, #87, #89, #90, #97, #98, #99, #107, #109, #110, #112, #119, #123, #124, #128, #129, #141, #145, #148, #149, #151, #560, #561 and #563 . The facility census was 167. Findings Include: During an environment tour with Housekeeping Director (HSD) #540 on 04/27/23 between 11:07 A.M. and 11:25 A.M. The following was observed and verified with HSD #540. 1. The privacy curtains of the rooms occupied by Residents #15, #19, #38, #40, #47, #52, #63, #69, #72, #79, #87, #89, #90, #98, #99, # #107, #109, #110, #112, #119, #123, #124, #128, #141, #145, #148, #149, #151, #560, #561 and #563 had significant levels of unknown substances and stains. 2. The air conditioning (AC) units in the rooms occupied by Residents #22, #35, #37 were covered by bath towels to prevent cold air from leaking in to the room. The AC unit in the room occupied by…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-27 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to implement their abuse policy and procedure in regards to reporting allegations of misappropriation to the Ohio Department of Health. This affected one resident (#180) of three residents (#33, #148, and #180) reviewed for abuse, neglect, and misappropriation of resident property. Findings include: Review of the medical record for Resident #180 revealed an admission date of 01/11/22 and a discharge date of 04/01/23. Diagnoses included anemia, chronic obstructive pulmonary disease, vascular dementia, cocaine dependence with withdrawal, and insomnia. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #180 had impaired cognition and required limited assistance of one staff for bed mobility, transfers, and ambulation. Review of the nurse practitioner note dated 02/01/23 at 10:06 A.M. revealed Resident #180 was found in the common area, was pleasantly demented, and upset that she has lost her purse. The note indicated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-27 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure timely reporting of misappropriation to the Ohio Department of Health. This affected one resident (#180) of three residents (#33, #148, and #180) reviewed for abuse, neglect, and misappropriation of resident property. Findings Include: Review of the medical record for Resident #180 revealed an admission date of 01/11/22 and a discharge date of 04/01/23. Diagnoses included anemia, chronic obstructive pulmonary disease, vascular dementia, cocaine dependence with withdrawal, and insomnia. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #180 had impaired cognition and required limited assistance of one staff for bed mobility, transfers, and ambulation. Review of the nurse practitioner note dated 02/01/23 at 10:06 A.M. revealed Resident #180 was found in the common area, was pleasantly demented, and upset that she has lost her purse. The note indicated nursing was to call her sister to see if she took the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-04-27 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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, interview, and record review, the facility failed to ensure treatments for skin impairments were provided as ordered for Resident #11. This affected one Resident (#11) of two residents reviewed for skin impairment. The facility census was 167. Findings include: Review of the medical record for Resident #11 revealed admission date of 03/22/22 and diagnoses including spastic quadriplegia cerebral palsy, multiple sclerosis, and Barrett's esophagus. Review of the Medicare Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed Resident #11 had intact cognition. Resident #11 required total two staff assistance for bed mobility and transfers. The assessment indicated Resident #11 was at risk for pressure injuries and had interventions including pressure reducing device for bed, applications of non-surgical dressings, and application of ointment or medications. Review of the plan of care dated 04/11/22 revealed Resident #11 was at risk for alterations in skin integrity related to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-27 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and review of the manufacturer formulary, the facility failed to change an enteral tube feeding bag per manufacturer guidelines. This affected one Resident (Resident #91) of two residents reviewed for tube feeding. The facility census was 167. Findings include: Review of the medical record for Resident #91 revealed an admission date of 08/15/19. Diagnoses included but were not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Parkinson's disease, dysphagia (difficulty swallowing), unspecified protein-calorie malnutrition, and adult failure to thrive. Review of the 03/17/23 quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #91 revealed a Brief Interview of Mental Status (BIMS) score of 11 which indicated Resident #91 had moderate cognitive impairment. Review of the activities of daily living (ADLs) portion of the assessment revealed Resident #91 had total dependence of two staff for bed mobility and transfer; total dependence of one staff for toileting, personal hygiene, and bathing, 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.
- Potential for harm · D2019-11-21 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure residents received all required notices prior to the discontinuation of the skilled services. This affected two (Residents #87 and #160) of three residents reviewed for beneficiary notices. The facility census was 194. Findings include: 1. Review of the medical record revealed Resident #87 was admitted to the facility on [DATE]. Review of the beneficiary notice worksheet provided during the annual survey revealed Resident #87 was discharged from skilled services on 10/04/19. Review of census records revealed Resident #87 remained in the facility. Review of the list of notices provided to Resident #87 prior to the discontinuation of skilled services revealed Resident #87's responsible party was notified of the Notice of Medicare Non-Coverage (NOMNC) via phone call on 10/03/19. Further review of notices given to Resident #87 revealed no Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) was provided to the responsible party as…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-11-21 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure medications for Resident #247 and Resident #167 were properly stored prior to administration and were not left unattended in the residents' rooms. This affected two residents (Residents #247 and #167) of 26 residents whose rooms were observed. The facility census was 194. Findings include: 1. Record review revealed Resident #247 was admitted to the facility on [DATE] with admitting medical diagnoses including anemia, congestive heart failure, type II diabetes, partial mastectomy, hypertension and right pneumothorax. Review of the resident's physician's orders dated 11/16/19 revealed orders for: Imbruvica 420 milligrams (mg) tablet to receive half of the tablet daily for cancer Simvastatin 40 mg by mouth daily for high cholesterol Metoprolol 50 mg daily for hypertension Sitagliptin-Metformin 50-1000 mg daily for diabetes Valsartan 160 mg daily for hypertension and heart failure Xarelto 10 mg daily, a blood thinner Cephalexin 500 mg…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-11-21 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, the facility failed to ensure reverse isolation protocol was followed as ordered for Resident #247. This affected one of one resident who was in reverse isolation. Findings include: Review of the medical record revealed Resident #247 was admitted to this facility on 11/16/19. Her admitting medical diagnoses included anemia, congestive heart failure, type II diabetes, partial mastectomy, hypertension and right pneumothorax. This resident's Minimum Data Set (MDS) 3.0 assessment was not completed due to the resident was a new admission. Interview with the resident on 11/18/19 at 8:30 A.M. revealed she was alert and oriented. She stated she could not get up, reposition herself or ambulate without assistance. Review of the physician orders dated 11/15/19 an order for protective reverse isolation precautions. The order further stated to wear gown, mask and gloves as needed. Wash hands when touching the environment and with direct patient care. All care activities and therapies were to be provided in the resident's room. The resident was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2023-04-27 · tag F0711 — patternEnsure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to ensure physicians orders were signed and dated. This affected five of 37 residents whose physician orders were reviewed, Residents #38, #47, #66, #80 and #93. The facility census was 167. Findings Include: 1. Medical record review revealed Resident #38 was admitted to the facility on [DATE] with diagnoses that included heart attack, urinary retention and malnutrition. Further review of the medical record revealed the monthly recapitulation of physician orders for March 2023 and February 2023 and telephone orders from 02/10/23 and 12/20/22 were not signed and dated by Resident #38's physician. 2. Medical record review revealed Resident #47 was admitted to the facility on [DATE] with diagnoses that included abnormal weight loss, pulmonary embolism and syphilis. Further review of the medical record revealed the monthly recapitulation of physician orders for April 2023, March 2023, February 2023, January 2023 and December 2022 and telephone orders…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to LEGACY HEALTH SERVICES — 10 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.5 | -0.5 vs chain |
| Health inspection | 3 of 5 | 2.7 | +0.3 vs chain |
| Staffing | 2 of 5 | 2.2 | -0.2 vs chain |
| Quality measures | 4 of 5 | 4.9 | -0.9 vs chain |
The other 9 homes this chain runs (chain average 3.5★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| OH 10 HOLDCO LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 07/06/2022 |
| CC OH10 OPCO LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/06/2022 |
| CHAVOS221 HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/06/2022 |
| CHAVOS221 IRRV TR | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/06/2022 |
| LIONSVIEW OPCO NR LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/06/2022 |
| LIONSVIEW SC LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/06/2022 |
| LIVING26 HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/06/2022 |
| LIVING26 IRRV TR | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/06/2022 |
| SAPPHIRE143 HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/06/2022 |
| SAPPHIRE143 IRRV TR | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/06/2022 |
| STUMP, BARRY | Individual | W-2 MANAGING EMPLOYEE; CORPORATE OFFICER | — | since 05/07/2019 |
| SHARVIT, ELIAV | Individual | CORPORATE OFFICER | — | since 06/22/2007 |
CMS files one row per role, so the 13 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted.
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.
This home reported $3.0M paid to related parties — landlords or management companies under common ownership — equal to about 15% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
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
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
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Ohio Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 365706. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-06-06, 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.