Otterbein Portage Valley
20311 Pemberville Rd, Pemberville, OH 43450 · Non profit - Corporation · 50 certified beds · (419) 833-7000 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 a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- nursing-staff turnover (64%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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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 | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 0.0% | 5.3% | 15.4% | check this* — see note marked star below the table |
| Long-stay residents who lose too much weight | 3.9% | 6.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.2% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.4% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 17.9% | 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 | 1.6% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 0.0% | 6.1% | 16.1% | check this* — see note marked star below the table |
| Long-stay residents on antianxiety or hypnotic medication | 16.7% | 25.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 97.1% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.5% | 3.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 31.9% | 21.4% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 10.6% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.8% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 86.5% | 75.6% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 27.0% | 24.9% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 5.1% | 12.9% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 0.65 | 1.73 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.32 | 1.80 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
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.
52.8% 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 124 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 66.7% 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 54 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 0.50 therapist hours per resident per day in 2026Q1 — more than 81% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 22% 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 | 52.8%CMS range 44.4–62.6 | 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 | 9.8%CMS range 7.3–12.9 | 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 | 66.7% | 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 | 53.7% | 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 | 48.1% | 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 | 89.7% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 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 | 4.4% | 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 | 5.7%CMS range 3.1–9.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.99 | 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 50 beds and averages 45.7 residents a day — about 91% occupied, or roughly 4 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 3.46 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.89 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.04 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 3.09 hrs/resident/day on weekends vs 3.60 on weekdays — 14% thinner on weekends. RN hours go from 1.00 to 0.61 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 64% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
27 citations, most serious first. The 11 most serious are shown; the remaining 16 are one tap away and print in full.
- Actual harm · Gcited before2022-11-28 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of hospital documentation, observation, staff interview, review of facility policy, and review of the National Pressure Injury Advisory Panel (NPIAP) guidance, the facility failed to complete accurate skin assessments, provide ongoing monitoring of pressure ulcers, failed to obtain treatment orders for pressure ulcers, and failed to provide a treatment to pressure ulcers for one resident (#39). This resulted in actual harm when Resident #39's left heel unstageable pressure ulcer had an increase in the amount of necrotic tissue present from 25% to 100% within eleven days. This affected one (#39) of one resident reviewed for pressure sores. The facility identified three residents with pressure sores. The facility census was 44. Findings include: Review of Resident #39's medical record revealed an admission date of 09/22/22 and a readmission date of 11/10/22. Diagnoses included difficulty in walking, dysphagia, asthma, multiple sclerosis, cognitive communication deficit,…
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 · D2026-04-15 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately 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, staff interview, and policy review, the facility failed to ensure the physician was timely notified of a change in condition related to a fall and the facility further failed to ensure the family was notified of a resident fall. This affected one (#46) of three residents reviewed for notification of change. The facility census was 44.Findings include:Review of Resident #46's medical record revealed an admission date of 12/19/25 and a discharge date of 01/06/26. Diagnoses included unspecified intracapsular fracture of left femur, chronic obstructive pulmonary disease (COPD), protein calorie malnutrition, Alzheimer's disease, pressure ulcer of sacral region stage three, and anemia.Review of Resident #46's Medicare - five day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 had severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of three. Furthermore, Resident #46 required supervision or touching assistance for chair to bed transfers, bed 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 · D2026-04-15 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, and policy review, the facility failed to ensure food that was opened was properly stored and stored. This had the potential to affect all residents as the facility verified all residents received food from the kitchen. The facility census was 44. Findings include:Observation on 04/13/26 at 8:03 A.M. of walk-in freezer #1 revealed cheese pizzas, a bag of pizza dough, a bag potato wedges, dinner rolls, brown bread, and a bag of diced onions were open and undated.Interview on 04/13/26 at 8:06 A.M. with Dietary Manager (DM) #97 verified the cheese pizzas, a bag of pizza dough, a bag potato wedges, dinner rolls, brown bread, and a bag of diced onions were open and undated. DM #97 verified any time food is opened, the food item should be marked with an open date.Review of the facility policy with a revision date of May 2013 titled Food Storage Policy and Procedure revealed the purpose of the policy was to assure all food is stored, labeled, and dated properly to ensure stock rotation and prevent foodborne illnesses. Furthermore, prepared food is 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 · Dcited before2025-06-18 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure monitoring of pressure ulcers. This affected one (#21) of one resident reviewed for pressure ulcers. The facility census was 45. Findings include: Review of the medical record for Resident #21 revealed an admission date of 05/26/25 with diagnoses of paraplegia, local infection of the skin and subcutaneous tissue, diabetes mellitus, anxiety, and depression. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #21 revealed he was cognitively intact and was admitted with wounds. Review of the admission assessment dated [DATE] revealed Resident #21 had an unstageable pressure ulcer to the sacrum (tailbone area) that measured 8.5 centimeters (cm) by 4.5 cm by 1.4 cm. Review of the current care plan revealed Resident #21 was care planned for wounds with an intervention in place for a wound vacuum (vac) as ordered. Review of the weekly skin assessments, dated 06/03/25 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 · D2025-06-18 · 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
Based on observation, medical record review, staff interview, and review of the facility policy, the facility failed to ensure oxygen was administered per physician orders. This affected one resident (#147) of one resident reviewed for oxygen therapy. The facility census was 45. Findings include: Review of the medical record for Resident #147 revealed an admission date of 05/09/25 with diagnoses of chronic obstructive pulmonary disease (COPD), malignant tumor of the bronchus and lung, anxiety, and dependence on oxygen. Review of the admission Minimum Data Set (MDS) assessment, dated 05/10/25, revealed Resident #147 had mild cognitive impairment and required the use of oxygen therapy. Review of the current physician orders revealed Resident #147 was ordered humidified oxygen at a rate of four liters per minute (LPM) to maintain oxygen saturation (measurement of how much oxygen is in the body) at 90% or above. Review of the care plan, initiated May 2025, revealed Resident #147 received oxygen therapy due to ineffective gas exchange and pulmonary hypertension. Interventions included 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 · D2025-06-18 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed medical record review, hospital record review, review of the Cubex (computerized medication dispensing machine, provided and maintained by the contracted pharmacy, for frequently used medications to be available for immediate use) inventory sheet, facility policy review and interviews with staff, pharmacy and family, the facility failed to implement a timely, effective and adequate pain management plan for Resident #143 following the resident's admission to the facility. This affected one (#143) of one resident reviewed for pain management. The facility census was 45. Findings include: Review of the closed medical record for Resident #143 revealed an admission date of 06/05/25 at 1:10 P.M. and a discharge date of 06/05/25 at 10:20 P.M. Resident #143 had diagnoses including low back pain, chronic pain syndrome, intervertebral disc degeneration-thoracic region, lumbosacral intervertebral disc degeneration, radiculopathy-lumbar region, spinal stenosis-lumbosacral region, spinal stenosis-lumbar…
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 · D2025-06-18 · 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 observation, staff interview, pharmacy staff interview, medical record review, closed medical record review, and review of the Cubex (computerized medication dispensing machine containing frequently used medications for immediate access for new admissions and/or new physician orders) machine inventory sheets, the facility failed to ensure medication doses were verified prior to administration and further failed to ensure available medications were administered per physician order. This affected two residents (#28 and #143) reviewed for medication administration. The facility census was 45. Findings include: 1. Review of the medical record for Resident #28 revealed an admission date of 11/01/24 with a diagnosis of depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 had mild cognitive impairment. Review of the current physician orders revealed Resident #28 was prescribed Wellbutrin XL (medication used to treat depression) oral tablet extended release…
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 · D2025-06-18 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, medical record review, and review of facility policy, the facility failed to ensure staff donned gloves prior to the administration of subcutaneous (injection of medication into the fatty tissue layer beneath the skin) medications. This affected one (#28) of one resident observed for subcutaneous medication administration. The facility census was 45. Findings include: Review of the medical record for Resident #28 revealed an admission date of 11/01/24 with a diagnosis of diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 revealed she had mild cognitive impairment. Review of the current physician orders revealed Resident #28 was prescribed liraglutide (non-insulin treatment for Type II diabetes) 18 milligrams (mg)/three milliliters (ml), inject 1.2 milligrams (mg) subcutaneously in the morning. Observation on 06/17/25 at 7:23 A.M. revealed Registered Nurse (RN) #637 prepared liraglutide for administration 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 · Dcited before2025-03-04 · 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
Based on medical record review, staff interview and review of facility policy, the facility failed to assess a newly identified bruise and further failed to ensure neurological assessments were completed following a head injury. This affected one (#11) of three residents reviewed for injuries. The facility census was 46. Findings include: Review of the medical record for Resident #11 revealed an admission date of 03/31/23 with diagnoses of dementia, anxiety, and osteoporosis. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/10/25, revealed Resident #11 had impaired cognition. Review of the hospital discharge records, dated 02/05/25, revealed Resident #11 was assessed at the hospital after a fall on 02/05/25. The documents revealed a head computed tomography (CT) scan showed a small focus of isodense extra-axial fluid on the right side that was probably a small, subacute subdural hematoma (a collection of blood between the brain and the skull). The plan included follow up in about six weeks with a new head CT. Further review revealed Resident #11 was at risk for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 medical record review, staff interview, review of electronic mail (e-mail) correspondence and review of facility policy, the facility failed to implement interventions to prevent a fall for one (#13) of three residents reviewed for falls. Additionally, the facility failed to complete neurological checks following an unwitnessed fall with injury and further failed to monitor injuries resulting from a fall per physician order. This affected one (#12) of three residents reviewed for falls. The facility census was 46. Findings include: 1. Review of the medical record for Resident #13 revealed an admission date of 11/23/16 with diagnoses of dementia and epilepsy. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/28/25, revealed Resident #13 was rarely/never understood, was dependent for transfers and used a wheelchair for mobility. Review of a Fall Risk Screening, dated 09/30/24, revealed Resident #13 was at risk for falls. Review of a nursing progress note dated 12/16/24 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.
- Potential for harm · D2025-03-04 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard 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, staff interview and review of the facility incident report, the facility failed to ensure fall incidents were documented in the resident medical record. This affected one (#12) of three residents reviewed for falls. The facility census was 46. Findings include: Review of the medical record for Resident #12 revealed an admission date of 11/22/24 with diagnoses of dementia, and muscle wasting and atrophy. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/13/25, revealed Resident #12 had impaired condition, was dependent for transfers and used a wheelchair for ambulation. Further review revealed Resident #12 had a fall with a non-major injury since the previous assessment. Review of the progress notes in Resident #12's electronic medical record dated 12/14/24 through 12/16/24 revealed no documentation of a fall. Review of the neurological assessments completed in Resident #12's electronic medical record revealed one was completed on 12/14/25 at 1:35 P.M. and the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 16 citations
- Potential for harm · D2025-01-23 · tag F0551 — isolatedGive the resident's representative the ability to exercise the resident's 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, medical record review, staff interview and review of the facility resident rights document, the facility failed to ensure requests made by a resident's guardian were adequately addressed. This affected one (#36) of one resident reviewed for requests made by a guardian. The facility census was 46. Findings include: Review of the medical record revealed Resident #36 admitted to the facility on [DATE]. Diagnoses included dementia, severe protein-calorie malnutrition, adult failure to thrive, and muscle weakness. Further review revealed Resident #36's daughter was appointed legal guardian on 12/04/24. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 was cognitively impaired. The resident required supervision or touching assistance for chair/bed-to-chair transfers. Review of the plan of care dated 09/06/23, and revised 01/21/25, revealed Resident #36 had an activities of daily living (ADLs) self-care and/or physical mobility performance deficit 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 · D2024-09-10 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of staff statements, observation of a video recording, interviews, and review of the Ohio Nursing Home Residents [NAME] of Rights, the facility failed to ensure a resident was treated with dignity and respect. This affected one (#26) of three residents reviewed for dignity and respect. The facility census was 48. Findings include: Review of the medical record for Resident #26 revealed an admission date of 08/25/23. Diagnoses included dementia, pulmonary fibrosis, and chronic obstructive pulmonary disease. Review of the quarter Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. The resident was always incontinent of bladder and occasionally incontinent of bowel. Review of an undated and unsigned statement by Registered Nurse (RN) #600 revealed on 08/13/24 Resident #26's daughters called and expressed after reviewing a video from their father's room, they saw and heard a nursing assistant yelling at their father and scolding him for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-23 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and staff interviews, the facility failed to ensure a resident who was dependent on staff for eating was assisted with eating with her meal. This affected one (Resident #16) of one resident observed for eating and had the potential to affect eight residents (#2, #4, #14, #28, #30, #31, #42, and #43) the facility identified as requiring assistance with eating. The facility census was 49. Findings include: Review of the medical record for Resident #16 revealed she was admitted on [DATE] with diagnoses of intracerebral hemorrhage with left sided paralysis and dysphagia. Review of the care plan revised 06/2024 revealed Resident #16 was care planned for Activity of Daily Living (ADL) self-care and/or physical mobility performance deficit. Interventions included to provide extensive assistance of one staff member for eating. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was cognitively impaired and dependent on staff assistance…
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 · D2024-05-30 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, medical record review, staff interview, review of manufacturer instructions, and review of facility policy, the facility failed to ensure medications were administered as ordered by the physician, within prescribed time frames, and in accordance with manufacturer instructions for use, resulting in a medication error rate above five percent (%). A total of four medications errors were observed out of 39 opportunities for a medication administration error rate of 10.26%. This affected one (#1) of three residents observed during medication administration. The facility census was 38. Findings include: Review of Resident #1's physician orders noted the medications and prescribed times as indicated; on 05/19/24, Advair Diskus Aerosol Powder Breath Activated 250-50 micrograms (mcg) per(/) dose (Fluticasone-Salmeterol) one inhale orally every 12 hours related to chronic obstructive pulmonary disease (COPD) with acute exacerbation of shortness of breath with prescribed times 8:00 A.M. and 8:00 P.M.; on 03/08/24, Ipratropium-Albuterol Solution 0.5-2.5 milligrams (mg)/3.0…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-30 · 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 observation, medical record review, staff interview, review of the manufacturer instructions, and review of the facility policy, the facility failed to ensure a resident was free from a significant medication error when medications were not administered as ordered by the physician. This affected one (#1) of three residents observed during medication administration. The facility census was 38. Findings include: Review of Resident #1's physician orders noted the medications and prescribed times as indicated; Humalog KwikPen Subcutaneous Solution Pen-injector 100 unit per milliliter (ml) (Insulin Lispro) inject as per sliding scale: if 141 - 180 = two units; 181 - 220 = three units; 221 - 260 = four units; 261 - 300 = five units; 301 - 350 = eight units; 351 - 400 = 10 units; 401+ Greater than 400 give 12 units and call physician, subcutaneously before meals and at bedtime related to type II diabetes mellitus. Observation on 05/30/24 at 9:20 A.M. noted Licensed Practical Nurse (LPN) #400 obtaining medications for Resident #1 from the medication cart outside the resident's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-07 · 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 observation, medical record review, staff interview, facility policy review, and review of manufacturer instructions, the facility failed to ensure insulin was administered as ordered. This affected one (#31) of seven residents observed for medication administration. The facility census was 38. Findings include: Review of the medical record for Resident #31 revealed an admission date of 07/24/23. Diagnoses included type II diabetes mellitus, hypertension, hypothyroidism, chronic obstructive pulmonary disease, obstructive sleep apnea, peripheral vascular disease, encephalopathy, major depressive disorder, and insomnia. Review of the current physician orders for Resident #31 revealed an order dated 04/05/23 for blood glucose levels to be obtained prior to meals with Novolog insulin administered subcutaneously (SQ) per sliding scale via a Flex Touch pen. The order for insulin to be given per sliding scale was for blood glucose levels between 140 milligrams per deciliter (mg/dL) and 199 mg/dL, inject two units of insulin; for blood glucose levels between 200 mg/dL and 249…
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 · E2022-11-28 · tag F0919 — failed to provide a working call system — patternMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and staff interview, the facility failed to ensure bathrooms accessible to residents were equipped with a call light. This had the potential to affect seven (Residents #7, #15, #21, #34, #246, #247 and #248) identified by the facility as being independently mobile and residing on the 200 hall. The facility census was 44. Findings include: Observations on 11/20/22 at 10:06 A.M., 11:09 A.M., 1:22 P.M. and 4:25 P.M. and on 11/21/22 at 7:37 A.M. and 10:00 A.M. of a bathroom located off the 200 hall dining room, revealed the bathroom door was open and there was no call light in the bathroom. Interview on 11/21/22 at 10:20 A.M. with the Regional Minimum Data Set Registered Nurse (RN) #313 verified the bathroom door was unlocked and the bathroom did not have a call light. RN #313 stated the bathroom was generally used for staff and visitors and confirmed the door should be closed and locked since there was no call light in the bathroom.
- Potential for harm · D2022-11-28 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, resident interview, and staff interview, the facility failed to ensure call lights were available to dependent residents. This affected one (Resident #4) of three residents reviewed for call lights. The facility census was 44. Findings include: Review of the medical record revealed Resident #4 was admitted on [DATE]. Diagnoses included heart disease, Alzheimer's Disease, polyosteoarthritis, hypertensive chronic kidney disease, generalized anxiety disorder, hyperlipidemia, essential (primary) hypertension, and generalized muscle weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. Resident #4 required total dependence for transfers, locomotion on and off unit, eating, toilet use, and personal hygiene. Observation on 11/20/22 at 1:52 P.M. revealed Resident #4 shouting for assistance. Resident #4 was observed to be in a wheelchair and was asking to go to bed. No call light device was observed 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 · D2022-11-28 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, family interview, staff interview, and review of the facility's admission packet, the facility failed to allow a resident to have medications provided by a pharmacy of choice. This affected one (Resident #5) of three residents reviewed for pharmacy preferences. The facility's census was 44. Findings include: Review of Resident #5's medical record revealed an admission date of 04/27/21. Diagnoses included chronic kidney disease, diabetes mellitus, sedative dependence, obstructive sleep apnea, fibromyalgia, and a history of breast cancer. Review of Resident #5's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required assistance with personal hygiene, toilet use, and dressing. Review of the social service note dated 02/15/22 revealed the facility's pharmacy contacted the facility regarding the Resident #5's outstanding bill. The social worker encouraged Resident #5 to reach out to the pharmacy if she had questions. Family…
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 · D2022-11-28 · 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 medical record review, review of the Notice of Medicare Non-Coverage (NOMNC), review of the Advanced Beneficiary Notice of Non-Coverage (ABN), review of the admission agreement, review of Medicare Part A Skilled Nursing Acknowledgement of Benefits and Co-Payments and staff interview, the facility failed to ensure a timely refund to a resident's representative following discharge. This affected one (#249) of three residents reviewed for conveyance of funds. The facility census was 44. Findings include: Review of Resident #249's medical record revealed an admission date of [DATE]. Diagnoses included atherosclerotic heart disease, hypertension, peripheral vascular disease, aphasia, Alzheimer's disease with late onset and dementia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #249 was moderately impaired for decision making, required extensive assistance with Activities of Daily Living (ADLs), received speech therapy (ST) and physical therapy (PT), and 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.
- Potential for harm · Dcited before2022-11-28 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, and staff interview, the facility failed to ensure residents who required assistance from staff with Activities of Daily Living (ADL) received adequate and timely assistance with grooming. This affected three (Residents #17, #10, and #40) of five residents reviewed for ADL care. The facility's census was 44. Finding include: 1. Review of Resident #17's medical record revealed an admission date or 1/21/16. Diagnoses included unspecified dementia, epilepsy, unilateral primary osteoarthritis left hip, hypertensive heart disease without heart failure, muscle weakness, and polyosteoarthritis. Resident #17 was a female resident. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was unable to complete the cognitive assessment of the interview. Resident #17 required extensive one person assistance with eating, dressing, and personal hygiene. Observations on 11/20/22 at 4:23 P.M., 11/21/22 at 8:13 A.M., and 11/22/22 at 9:13 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.
- Potential for harm · Dcited before2022-11-28 · 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 medical record review, observation, and staff interview, the facility failed to provide physician ordered ted hose for Resident #26. This affected one (Resident #26) of one resident reviewed for ted hose orders. Additionally, the failed to complete a timely urinalysis for Resident #28. This affected one (Resident #28) of one resident reviewed for urinalysis timeliness. The facility census was 44. Findings include: 1. Review of Resident #26's medical record revealed an admission date of 04/08/22. Diagnosis included cerebral infarction with hemiplegia affecting the dominant side, chronic obstructive pulmonary disease, congestive heart failure, and diabetes mellitus. Review of Resident #26's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a high cognitive function. Review of Resident #26's most recent care plan revealed due to immobility, diabetes mellitus, hemiplegia, anemia, morbid obesity the resident was care planned for ted hose. Review of Resident #26's physician's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-11-28 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and review of facility policy, the facility failed to ensure pneumococcal vaccinations were administered. This affected one (Resident #35) of five residents reviewed for pneumococcal vaccination. The facility census was 44. Findings include: Review of Resident #35's medical record revealed an admission date of 09/20/22. Diagnoses included disorientation, acute kidney failure, major depressive disorder, sepsis, hypertension and atrial fibrillation. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 was moderately cognitively impaired and was not up to date on the pneumococcal vaccination. Review of Resident #35's immunizations revealed the resident received the influenza vaccine on 10/26/22, declined the COVID-19 vaccination on 10/26/22 and the Prevnar 20 (pneumococcal vaccine) was required. Review of a consent form signed 09/20/22 revealed Resident #35 consented to the pneumococcal vaccination. Interview on 11/22/22 at…
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 before2020-01-04 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure accurate wound measurements were completed for a pressure ulcer. This affected one resident (#141) of two residents reviewed for pressure ulcers. The facility identified four residents with pressure ulcers. Findings included: Review of Resident #141's medical record revealed an admission date of 12/24/19. Diagnoses included pressure ulcer sacral area stage four (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed), osteomyelitis, depressive disorder, anxiety, hypertension, sleep apnea, paraplegia, diabetes mellitus and Methicillin resistant staphylococcus aureus. Review of Resident #141's hospital wound measurements, dated 12/13/19, revealed a stage four coccyx wound which measured 3.5 centimeters (cm.) in length by 6.5 cm. in width by 3.5 cm. deep. Review of the physician order, dated 12/24/19, revealed an order to cleanse coccyx with normal saline pat dry. Soak the four by four gauze…
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 · D2020-01-04 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — the official record, unedited, may be distressing
Based on medical record review and staff interview, the facility failed to ensure a resident's dialysis fistula was monitored. This affected one resident (#142) of one resident who received dialysis services. Findings Include: Review of Resident #142's medical record revealed an admission date of 01/01/20. Diagnoses included end stage renal disease and diabetes mellitus. Review of Resident #142's care plan revealed the resident was receiving dialysis related to end stage renal disease. Interventions included to monitor/check for bruit and thrill each shift. Review of the Treatment Administration Record (TAR), dated January 2020, revealed the record to be absent of documentation the resident's dialysis fistula was being monitored. Further review of the resident's progress notes revealed one note on admission of an assessment of the dialysis fistula. Interview on 01/04/20 at 9:14 A.M. with Registered Nurse (RN) #410 verified there was no documentation of Resident #142's dialysis fistula being monitored. RN #410 stated the documentation would be included on the resident's TAR.
- No harm found · C2024-09-10 · tag F0607 — failed to have anti-abuse policies — widespreadDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — the official record, unedited, may be distressing
Based on review of personnel records, staff interview, and policy review, the facility failed to ensure employee reference checks were completed. This had the potential to affect all residents. The facility census was 48. Findings include: Review of the personnel record for State Tested Nursing Assistant (STNA) #210 revealed a hire date of 04/11/23. Further review of the personnel record revealed reference checks had not been completed. Interview on 09/10/24 at 11:56 A.M., the Administrator revealed the facility was unable to find any documentation of completed reference checks for STNA #210. Review of the policy, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, last revised 10/25/22 revealed prior to hiring a new employee the facility would attempt to obtain information from previous employers or current employers.
“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 OTTERBEIN SENIORLIFE — 20 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 3.2 | +0.8 vs chain |
| Health inspection | 3 of 5 | 3.0 | ≈ chain avg |
| Staffing | 3 of 5 | 3.2 | -0.2 vs chain |
| Quality measures | 5 of 5 | 4.1 | +0.9 vs chain |
The other 19 homes this chain runs (chain average 3.2★, 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 |
|---|---|---|---|---|
| OTTERBEIN LSC, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 01/01/2016 |
| OTTERBEIN HOME | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 100% | since 12/01/2021 |
| BARBEE, DANIEL | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 12/01/2021 |
| BENEDICT, JUDY | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 01/01/2024 |
| BOWLUS, MARILYN | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 01/01/2014 |
| GODFREY, MIKE | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 01/01/2024 |
| HINDS, NORRIS | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 04/01/2021 |
| KYLLO, THOMAS | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 01/01/2015 |
| LOAR, TARA | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 01/01/2025 |
| MCKIBBIN, KATIE | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 01/01/2023 |
| POWELL, ANGIE | Individual | CORPORATE DIRECTOR | — | since 11/24/2014 |
| STEPHENSON, JOHN | Individual | CORPORATE DIRECTOR | — | since 08/09/1982 |
| GREEN, JAMES | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 11/21/2005 |
| HAWKINS, RITA | Individual | CORPORATE OFFICER | — | since 01/16/2006 |
| MILLER, JASON | Individual | CORPORATE OFFICER | — | since 08/04/2014 |
| WILSON, JILL | Individual | CORPORATE OFFICER | — | since 05/01/2009 |
| FUNCTIONAL PATHWAYS OF TENNESSEE LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/04/2025 |
| APP, LYNN | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2021 |
| BARTLETT, VICTORIA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2021 |
| BAYLIFF, BECKY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2021 |
| BROWNSON, WILLIAM | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2021 |
| BURKE, DANIEL | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2021 |
| COLEMAN, ROBERT | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2021 |
| FRALEY, RALPH | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2021 |
| GLOSSER, HEIDI | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2021 |
| HAZELBAKER, TOMAS | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2021 |
| KIRKENDALL, JESSICA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/03/2023 |
| PIERCE, JOHN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/01/2021 |
| VONDERHAAR, STEVE | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2021 |
| BAKER, STEVE | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 04/04/2025 |
| GALBUT, ABRAHAM | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 04/04/2025 |
| GALBUT, DANIEL | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 04/06/2025 |
| GALBUT, DAVID | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 04/04/2025 |
| GALBUT, ERIC | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 04/06/2025 |
| GALBUT, ROBERT | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 04/04/2025 |
| PARITZKY, JONATHAN | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 04/04/2025 |
| ROMBRO, DAVID | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 04/04/2025 |
| ZISEK, TODD | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 04/04/2025 |
| POLARIS PHARMACY SERVICES OF OHIO LLC | Organization | ADP OF THE SNF | — | since 12/01/2018 |
CMS files one row per role, so the 53 rows in the source record cover these 39 parties — each is shown once here with every role it holds. Nothing is omitted.
4 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 $371K paid to related parties (affiliated landlords or management companies) in its most recent cost report. 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 365571. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-18, 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.