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The Pavilion At Piketon

7143 Route 23 South, Piketon, OH 45661 · For profit - Limited Liability company · 155 certified beds · (740) 289-2394 Medicare & Medicaid certified

Call the home — (740) 289-2394 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Apr 2025Behavioral-health or dementia-care citations — no harm found (F0740, F0758)2 actual-harm citations
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (1/5)
  • nursing-staff turnover (59%) runs well above the national median (45%)
  • about 21% of its spending goes to commonly-owned related companies

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

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

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 5 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
100 Indian Ridge Dr · (740) 289-1548 · Call to confirm hours
Pharmacy
104 Thornton Dr · (740) 648-3020 · Call to confirm hours
Grocery
577 S West St · (740) 443-6303 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
723 S West St

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

Quality measures — how residents actually fare

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

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

Trend — is this home getting better or worse?

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

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

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased5.1%5.3%15.4%typical for the state — see note marked double-dagger below the table
Long-stay residents who lose too much weight7.0%6.2%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.2%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.4%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms11.6%30.1%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.1%3.2%3.3%better
Long-stay residents whose ability to walk worsened6.8%6.1%16.1%worse than state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication32.1%25.5%18.9%worse
Long-stay residents given the seasonal flu vaccine83.5%94.5%95.3%worse
Long-stay residents with pressure ulcers5.0%3.4%4.7%typical
Long-stay residents with worsening bladder/bowel control17.8%21.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table10.1%8.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine64.4%75.6%79.4%worse
Short-stay residents rehospitalized after admission10.5%24.9%22.6%better
Short-stay residents with an outpatient ER visit17.0%12.9%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.371.731.67better
Long-stay outpatient ER visits per 1,000 resident days4.531.801.80worse

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.

47.3% 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 49 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

47.3%U.S. median 51.5%
Got home and stayed home
13.5%U.S. median 10.7%
Went back to hospital
61.9%U.S. median 56.6%
Met the expected recovery
0.65U.S. median 0.31
Therapy hours / resident / day
0.28hours / resident / day
Physical therapy
0.32hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 61.9% 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 21 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 0.65 therapist hours per resident per day in 2026Q1 — more than 90% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 10% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF47.3%CMS range 34.6–64.151.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF13.5%CMS range 10.2–17.610.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge61.9%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge57.1%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge33.3%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay2.7%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.7%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.351.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.50
RN hours/ resident / day
0.95
LPN hours/ resident / day
2.48
Aide hours/ resident / day
3.92
Total nurse hours/ resident / day
0.35
RN hoursweekends
59.0%
Total nursing turnover
55.6%
RN turnover

How full it usually is: this home is certified for 155 beds and averages 84.9 residents a day — about 55% occupied, or roughly 70 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.92 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.50 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.48 is at or above 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 3.55 hrs/resident/day on weekends vs 4.08 on weekdays — 13% thinner on weekends. RN hours go from 0.56 to 0.35 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 59% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

5
deficiencies at the latest standard inspection (2025-04-17)
15
at the previous standard inspection (2024-01-29)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

27 citations, most serious first. The 12 most serious are shown; the remaining 15 are one tap away and print in full.

  • Actual harm · Gcited before2024-01-29 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, observation, staff interview, and facility policy review, the facility failed to develop and implement comprehensive and individualized interventions to prevent the onset of joint contractures for Resident #38. Actual harm occurred on 01/10/24 when Resident #38, who was admitted to the facility without contractures was assessed to have developed contractures to the third and fourth fingers on the left and right hands which caused pain upon range of motion for the resident due to a lack of interventions to prevent the contractures from occurring. This affected one (Resident #38) of one resident reviewed for range of motion. The facility census was 84. Findings include: Review of the medical record for Resident #38 revealed an admission date of 10/12/23 with diagnoses including fracture of lumbar vertebra, chronic respiratory failure, chronic obstructive pulmonary disease (COPD), diabetes mellitus, morbid obesity, hypertension, hyperlipidemia, chronic kidney disease, atrial fibrillation, congestive heart failure, encephalopathy, osteoarthritis, anemia,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2024-01-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, review of hospital progress notes, review of the facility policy, and review of manufacturer's guidelines, the facility failed to ensure Resident #70 was provided adequate and necessary interventions to prevent falls including a fall with injury and failed to ensure post-fall investigations were completed for Resident #69. This affected two residents (Resident #69 and #70) of four residents reviewed for falls. The facility census was 84. Actual harm occurred on 11/29/23 when Resident #70, who was moderately cognitively impaired, at risk for falls and care planned to require the use of hipsters (a type of garment worn to help reduce the risk of injuries from a fall, such as hip fractures, through impact-absorbing foam pads over the critical fracture area) sustained a fall with increased pain and subsequent left hip fracture when not wearing the hipsters as care planned. As a result of the fall, the resident was hospitalized and required surgical…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-17 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility policy titled Abuse, Neglect, Exploitation, or Misappropriation-Reporting and Investigating, and interviews, the facility failed to appropriately report an allegation of resident to resident abuse to the proper agencies. This affected one resident (Resident #73) out of three reviewed for abuse. The facility census was 102. Findings include: Review of the medical record for Resident #73 revealed this resident was admitted to the facility on [DATE] with the following medical diagnoses: diabetes mellitis type II, post-traumatic stress disorder, muscle weakness, Bipolar disorder, psychoactive substance abuse, altered mental status, dysphagia, lack of coordination, low back pain, alcohol abuse, nicotine dependence, hypertension, and gastro-esophageal reflux disease. This resident is alert and oriented and has minimal cognitive deficits according to the Minimum Data Set (MDS) assessment completed on 03/22/25. Review of nursing notes from 4/12/25 at 10:35 A.M. revealed…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-17 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interview, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR) was accurately completed. This affected one resident (#71) out of the six residents reviewed for PASARR during the annual survey. The facility census was 102. Findings include: Record review for Resident #71 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included epilepsy, seizures, mood disorder, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/07/25, revealed the resident was assessed to have intact cognition. Review of the residents physicians orders from 06/06/24 through 06/13/24 revealed the resident was ordered Buspar (an anti-anxiety medication) and Sertraline (an anti-depressant medication). Review of the PASARR, signed as completed on 06/13/24, revealed the resident was assessed to have not been ordered any psychotropic medications (anti-anxiety, anti-depressant, anti-psychotic, or mood…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-17 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide timely podiatry care and services to Resident #3. This affected one (Resident #3) of four residents reviewed for activities of daily living. The facility census was 102. Findings include: Review of the medical record for Resident #3 revealed an admission date of 01/17/25 with diagnoses including infection/inflammation reaction due to internal joint prosthesis, osteoarthritis, paint in left knee and major depressive disorder. Review of the physician orders for Resident #3 revealed an order received on admission to see podiatry as needed. Review of the Medicare 5 day Minimum Data Set (MDS) dated [DATE] revealed Resident #3 was cognitively intact and required partial to moderate assistance to complete activities of daily living. Review of the nursing progress notes for Resident #3 revealed no documentation of the condition of Resident #3 toe nails. The progress notes did not indicate Resident #3 had been seen by a podiatrist. Review of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-17 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, record review, observation, and document review the facility failed to ensure residents were free of significant medication errors when staff failed to prime an insulin pen for Resident #90. This affected one (Resident #90) of five residents reviewed for medication administration. The facility census was 102. Findings include: Record review of Resident #90 revealed an admission date of 02/03/25 with pertinent diagnoses of: sepsis, osteomyelitis, type two diabetes mellitus, hypertension, acquired absence of right and left lower leg below knee. Review of the 02/06/25 modification of admission and medicare five day Minimum Data Set (MDS) assessment revealed the resident is cognitively intact and uses a wheelchair to aid in mobility. Review of Physician Order dated 02/04/25 revealed Humalog injection solution 100 unit/milliliter (insulin Lispro) inject as per sliding scale if 150-200= 3 units; 201-250= 6 units; 251-300= 9 units; 301-350=12 units; 351-400=15 units; 401+= 18 units notify Nurse Practitioner, subcutaneously before meals and and bedtime for diabetes…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-17 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, record review, observation, and document review, the facility failed to appropriately clean a blood glucose monitoring machine between patient uses. This affected one (Resident #90) of five residents reviewed for medication administration. This had the potential to affect three Residents (Resident #90, #298, and #303) who resided on the E hallway and received blood sugar glucose monitoring. The facility census was 102. Findings include: Record review of Resident #90 revealed an admission date of 02/03/25 with pertinent diagnoses of: sepsis, osteomyelitis, type two diabetes mellitus, hypertension, acquired absence of right and left lower leg below knee. Review of the 02/06/25 modification of admission and medicare five day Minimum Data Set (MDS) assessment revealed the Resident is cognitively intact and uses a wheelchair to aid in mobility. Review of Physician Order dated 02/04/25 revealed Humalog injection solution 100 unit/milliliter (insulin Lispro) inject as per sliding scale if 150-200= 3 units; 201-250= 6 units; 251-300= 9 units; 301-350=12 units;…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-01-29 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure target behaviors were identified and monitored in conjunction with the use of anti-psychotic medications. This affected four (Residents #15, #54, #59, and #76) of 22 facility-identified residents with orders for anti-psychotic medications. The facility census was 84. Findings include: 1. Review of the medical record for Resident #15 revealed an admission date of 09/07/23 with diagnoses including bipolar disorder, dementia with other behavioral disturbances, and hallucinations. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #15 dated 12/20/23, revealed the resident was mildly cognitively impaired and received anti-psychotic medication on a routine basis. Review of the physician's orders for Resident #15 revealed an order dated 11/30/23 for Seroquel (an anti-psychotic medication) 300 milligrams (mg) once a day in the evening related to bipolar disorder. Review of the care plan for Resident #15 initiated 09/07/23 revealed the care plan did not include…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-01-29 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and staff interview the facility failed to maintain a clean and functional environment with evidence of poor repair to five rooms that required wall repairs, room heater repairs, and painting. This affected five residents in rooms numbered B-1, B-5, B-8, B-12, and F-64. The facility census was 84. Findings include: Observation on 01/17/24 at 2:30 P.M. of Room B-12 with the Administrator revealed a large hole in the wall between the outside window and the wall heater. Cold air from outside was blowing into the room through the hole. Areas behind both beds had exposed dry wall and other exposed areas from missing paint with large holes in the drywall observed. The vent screen on the heating unit was visibly rusty and unpainted. Observation on 01/17/24 at 2:35 P.M. of Room B-8 with the Administrator revealed there were large, unrepaired holes in the drywall behind both resident beds and holes under the clock and across the room in the middle of the wall. There were some areas of exposed dry wall between the beds. Observation on 01/17/24 at 2:40 P.M. of Room B-5…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-29 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, resident representative interview, staff interview, and facility policy review, the facility failed to ensure resident representatives were notified of significant changes in resident status. This affected one (Resident #78) of 22 sampled residents. The facility census was 84. Findings include: Review of the medical record for Resident #78 revealed an initial admission date of 08/02/23 with diagnoses including cerebrovascular accident (CVA) with right-sided hemiplegia, osteoarthritis, subarachnoid hemorrhage, frontal lobe and executive function deficit following CVA, major depressive disorder, anxiety disorder, migraine, obstructive sleep apnea, hypertension, and hyperlipidemia. Review of the plan of care for Resident #78 dated 08/03/23 revealed the resident was at risk for impaired nutritional status related to hypertension, left hip arthroplasty, CVA, gastrostomy without tube feeding, hypertension, hyperlipidemia, obesity and weight loss. Interventions included the following: give medications for hypertension as ordered, monitor vital signs 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-29 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview the facility failed to ensure the accuracy of resident assessments. This affected two (Residents #15 and #60) of 22 sampled residents. The facility census was 84. Findings include: 1. Review of the medical record for Resident #60 revealed an admission date of 01/19/22 with diagnoses including quadriplegia, acute respiratory failure, aphasia, dysphagia, and severe protein calorie malnutrition Review of the care plan for Resident #60 dated 09/08/23 revealed the resident had an order for hospice care due to terminal diagnoses of intracranial hemorrhage. Interventions included the following: allow resident time and the opportunity to discuss his situation as needed, check with resident to see if he/she would like clergy visits, hospice care to be provided by hospice agency of resident's or family's choice, refer family to grieving support groups as needed, resident to be kept comfortable and as pain free as medically possible. Review of the quarterly MDS assessment…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-29 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review and staff interview, the facility failed to ensure resident Pre-admission Screening and Resident Review (PASARR) documents were accurate regarding resident current conditions and diagnoses and were completed when appropriate. This affected two (Residents #25 and #59) of four residents reviewed for PASARR documents. The census was 84. Findings include: 1.Review of the medical record for Resident #59 revealed an admission date of 08/07/21 with diagnoses including diabetes mellitus type II, drug induced subacute dyskinesia, depression, seizures, hypertension, and anxiety. Further review of the medical record revealed a diagnosis of unspecified psychosis was added for Resident #59 on 05/23/22. Review of the Minimum Data Set (MDS) assessment for Resident #59 dated 01/13/23 revealed the resident was severely impaired for cognition. Review of the PASARR document for Resident #59 dated 07/31/21 revealed it did not include any psychiatric diagnoses for the resident. Interview on 01/22/24 at 2:28 P.M. with the Administrator confirmed the facility should have…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 15 citations
  • Potential for harm · D2024-01-29 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review and staff interview, the facility failed to ensure comprehensive care plans were developed and implemented to reflect the need for care in the area of Post Traumatic Stress Disorder (PTSD) and Preadmission Screening and Resident Review (PASARR) recommendations. This affected one (Residents #76) of 22 residents reviewed for care planning. The facility census was 84. Findings include: Review of the medical record for Resident #76 revealed an admission date of 11/01/23 with diagnoses including schizophrenia, bipolar disorder, anxiety, and PTSD. Review of the admission Minimum Data Set (MDS) assessment for Resident #76 dated 11/07/23 revealed the resident was cognitively intact. Review of the Notice of Level II PASARR Outcome for Resident #76 dated 10/16/23 revealed based on the information provided in the Level II assessment and current records, Resident #76 met inclusion criteria for serious mental illness with diagnoses of schizophrenia, bipolar disorder, nicotine dependence, anxiety disorder, and PTSD. Specialized services and support nursing facility…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-29 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, observation, staff interview, and facility policy review, the facility failed to ensure staff provided assistance with nail care and routine shaving for dependent residents. This affected two (Residents #38 and #78) of four residents reviewed for activities of daily living (ADLs). The facility census was 84. Findings Include: 1. Review of the medical record for Resident #38 revealed an admission date of 10/12/23 with diagnoses including fracture of lumbar vertebra, cardiac arrest, chronic respiratory failure, chronic obstructive pulmonary disease (COPD), diabetes mellitus, morbid obesity, hypertension, constipation, gastro-esophageal reflux disease, hyperlipidemia, chronic kidney disease, atrial fibrillation, congestive heart failure, osteoarthritis, anemia, anxiety disorder, and major depressive disorder. Review of the plan of care for Resident #38 dated 10/26/23 revealed the resident had a self-care deficit related to COPD. Interventions included the following: therapy evaluation and treat as needed, refuses care/risk and benefits with encouragement…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-29 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, observation, staff interview, facility policy review, and review of guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to ensure pressure ulcers were thoroughly assessed and failed to ensure treatments for pressure ulcers were completed as ordered. This affected one (Resident #57) of five residents reviewed for pressure ulcers. The facility census was 84. Findings include: Review of the medical record for Resident #57 revealed an initial admission date of 06/19/23 with the latest readmission of 11/07/23 with diagnoses including severe protein calorie malnutrition, chronic respiratory failure, severe morbid obesity, diabetes mellitus, chronic obstructive pulmonary disease (COPD), stage IV pressure ulcer sacral region, chronic kidney disease, hypertension, hyperlipidemia, and congestive heart failure. Review of the admission assessment for Resident #57 dated 06/20/23 revealed the resident was admitted to the facility with an unstageable pressure ulcer to the sacrum measuring 1.5 centimeters (cm) by 1.0 in length 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-29 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, observation, and staff interview the facility failed to ensure accurate monitoring regarding resident consumption of physician ordered snacks. This affected one (Resident #54) of the three residents reviewed for nutrition. The facility census was 84. Findings include: Review of the medical record for Resident #54 revealed an admission date of 12/06/21 with diagnoses including dementia, aphasia, psychosis, aphasia, vitamin B12 deficiency, and altered mental status. Review of the annual Minimum Data Set (MDS) assessment for Resident #54 dated 12/06/23 revealed the resident was cognitively impaired, was coded negative for significant weight loss, and received a mechanically altered diet. Review of the care plan for Resident #54 revised 01/12/24 revealed the resident was at risk for impaired nutritional status. Interventions included staff should provide snacks three times a day. Review of the physician orders for Resident #54 revealed an order dated 08/16/23 for the resident to receive three snacks a day. Review of the Medication Administration Record…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-29 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure oxygen saturation levels and respiratory rates were monitored as ordered by the physician for residents with impaired respiratory status. This affected one (Resident #21) of two residents reviewed for respiratory care. The facility census was 84. Findings include: Review of the medical record for Resident #21 revealed an admission date of 07/16/23 with diagnoses including vascular dementia, shortness of breath, chronic obstructive pulmonary disease (COPD), and nicotine dependence. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #21 dated 10/20/23 revealed the resident was mildly cognitively impaired. Review of the care plan for Resident #21 dated 07/28/23 revealed the resident was at risk for impaired gas exchange related to shortness of breath and COPD. Interventions included monitor oxygen saturation as ordered and as needed. Review of the physician's orders for Resident #21 revealed an order dated 08/29/23 to obtain vital signs every Wednesday…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-29 · tag F0699 — isolated
    Provide care or services that was trauma informed and/or culturally competent.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review and staff interviews the facility failed to ensure residents with post-traumatic stress disorder (PTSD) were appropriately assessed with care plans implemented to minimize triggers and/or re-traumatization. This affected one (Resident #76) of two facility-identified residents with PTSD/history of trauma. The facility census was 84. Findings include: Review of the medical record for Resident #76 revealed an admission date of 11/01/23 with diagnoses including PTSD, schizophrenia, bipolar disorder, and anxiety. Review of the admission Minimum Data Set (MDS) assessment for Resident #76 dated 11/07/23 revealed the resident was cognitively intact and was coded for an active and current diagnosis of PTSD. Review of the care plan for Resident #76 initiated 11/01/23 revealed the plan did not identify the cause of the resident's PTSD, triggers which could cause re-traumatization and/or interventions to reduce the risk of re-traumatization and provide care for PTSD symptoms. Interview on 01/22/24 at 9:20 A.M. with the Director of Nursing (DON) confirmed the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-29 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure residents were free of significant medication errors. This affected one (Resident (#54) out of the five residents reviewed for unnecessary medications. The facility census was 84. Findings include: Review of the medical record for Resident #54 revealed an admission date of 12/06/21 with diagnoses including dementia, psychosis, and hypothyroidism. Review of the physician's orders for Resident #54 revealed an order dated 07/28/23 for 100 micrograms (mcg) of levothyroxine sodium (a thyroid hormone) once a day for hypothyroidism. Review of the laboratory results for Resident #54 dated 11/27/23 revealed the resident had a thyroid stimulating hormone (TSH) level of 0.139 milliunits per liter (mU/L) which was a below normal result indicating the need for decreased thyroid hormone. The normal range was 0.4 to 4.0 mU/L. Further review revealed Nurse Practitioner (NP) #500 reviewed the laboratory result on 11/29/23 and documented an order at the bottom of the page to decrease the dose…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-29 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview the facility failed to ensure physician visit notes were accurately documented in the resident medical record. This affected one (Resident #15) of 22 resident records sampled. The facility census was 84. Findings include: Record of the medical record for Resident #15 revealed an admission date of 09/07/23 with diagnoses including bipolar disorder, dementia with behavioral disturbance, and history of falling. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #15 dated 12/20/23 revealed the resident had mildly impaired cognition. Review of the nurse progress notes for Resident #15 revealed the resident was sent to the emergency room and was admitted to hospital on [DATE]. The resident was readmitted to the facility on [DATE]. Review of the physician progress note for Resident #15 dated 11/16/23 revealed the physician examined the resident in the facility for a 60-day regulatory visit. Interview on 01/18/24 at 8:00 A.M with the Director of…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2022-05-19 · tag F0868 — widespread
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and staff interview the facility failed to ensure quarterly Quality Assessment and Assurance (QAA) meetings were conducted. This had the potential to affect all 84 residents residing in the facility. Findings Include: Review of the QAA sign in sheets from 2021 and 2022 revealed meetings were held on 07/29/21 and 11/19/21. The facility failed to provide any additional sign in sheets to reflect quarterly meetings being conducted. Interview with the Administrator on 05/19/22 at 1:50 P.M. verified no further meeting sign in sheets could be found or provided as the only records were from meetings held on 07/29/21 and 11/19/21.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-05-19 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview the facility failed to provide residents a comfortable and homelike environment. This affected five residents (#2, #19, #329, #75 and #64) of five residents interviewed regarding the environment. Findings Include: On 05/16/22 at 9:35 A.M. interview with Resident #2 revealed he had a complaint about Resident #45 always yelling. Resident #2 stated Resident #45 was keeping him awake because he yells 12 hours per day. Resident #2 further stated he had told several staff about the noise, but nothing had changed. On 05/18/22 at 9:20 A.M. a follow up interview requested by Resident #2 was conducted. Resident #2 revealed he was concerned Resident #64 might hurt Resident #45 because the resident (#45) had been yelling all night again. Resident #2 did not state when or how Resident #64 would hurt Resident #45. On 05/18/22 from 9:24 A.M. through 9:30 A.M. an observation revealed Resident #45, who was in his room was yelling and could be heard up to four rooms away. The call light for Resident #45 was not ringing or lit up at the time. Resident #45 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-05-19 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, facility policy and procedure review and interview the facility failed to communicate with therapy about range of motion and assistive device recommendations for Resident #23 and failed to ensure restorative range of motion was provided as ordered and addressed in the plan of care for the resident. This affected one resident (#23) of five residents reviewed for range of motion. Findings Include: Review of the medical record for Resident #23 revealed an admission date of 06/02/16 with diagnoses including chronic pulmonary edema, aphasia, mixed hyperlipidemia, sequelae of protein-calorie malnutrition, Alzheimer's disease, dysphagia, contracture of right ankle and right hand, major depression disorder, anorexia, hemiplegia affecting right side, cognitive communication deficit and cerebral infarction. Review of the restorative plan of care, dated 03/15/21 revealed Resident #23 was at risk for a decline in functional range of motion related to limited mobility. A decline was…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-05-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure fall interventions were in place for Resident #50 to prevent falls. This affected one resident (#50) of three residents reviewed for falls. Findings include: Review of the medical record for Resident #50 revealed the resident was admitted to the facility on [DATE] with diagnoses including hyperlipidemia, type two diabetes mellitus, dysphagia, chronic obstructive pulmonary disease, hemiplegia and hemiparesis affecting right dominant side, mood disorder, aphasia, cerebral infarction, cognitive communication deficit and major depression. Review of the plan of care, initiated 08/31/20 revealed Resident #50 was at risk for falls related to impaired balance, impaired mobility, hemiplegia, incontinence, pain, seizures, dizziness, and history of falls. Resident #50 had been educated and encouraged related to safety needs however, she continued to self-transfer and self-ambulate without asking for assistance. Interventions included anti-roll…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-05-19 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility policy and procedure review and interview the facility failed to monitor meal and supplement intake for Resident #23 who had a significant weight loss. This affected one resident (#23) of seven residents reviewed for nutrition. Findings Include: Review of the medical record for Resident #23 revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic pulmonary edema, aphasia, mixed hyperlipidemia, sequelae of protein-calorie malnutrition, Alzheimer's disease, dysphagia, contracture right ankle and right hand, major depression disorder, anorexia, hemiplegia affecting right side, cognitive communication deficit and cerebral infarction. Review of the plan of care, dated 11/03/21 revealed Resident #23 was at nutritional risk related to diagnoses of depression, dementia, dysphagia, hyperlipidemia, hypertension, and malnutrition, and poor meal intakes, weight fluctuations related to variable meal intakes, refusing meals at times and history of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-05-19 · tag F0740 — failed to provide behavioral / mental-health care — isolated
    Ensure each resident must receive and the facility must provide necessary behavioral health care and 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 develop and implement a comprehensive and individualized behavior management plan to address the total care needs of Resident #45 and to decrease and/or eliminate yelling behaviors the resident was exhibiting. This affected one resident (#45) of one resident reviewed for accommodation of needs. Findings Include: A review of the medical record for Resident #45 revealed an admission date of 01/25/21 with diagnoses including paraplegia, hemiplegia to left hand, end stage renal disease, paralytic syndrome and chronic respiratory failure. A review of the resident's care plans revealed no plan of care related to or addressing behaviors or difficulty with range of motion to the resident's upper and lower extremities. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 04/04/22 revealed Resident #45 was alert and oriented, able to make decisions, was dependent on staff for mobility and had a pressure injury wound to his sacrum. The MDS assessment also revealed Resident #45 had impaired range of motion to both…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-05-19 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to provide an appropriate diagnosis for the use of antipsychotic medication for Resident #51. This affected one resident (#51) of five residents reviewed for unnecessary medication use. Findings Include: Record review for Resident #51 revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, muscle weakness, depression, hypertension, anxiety, insomnia, Vitamin D deficiency, seizures, dementia, falls and diabetes mellitus type II. Review of the Minimum Data Set (MDS) 3.0 assessment, completed on 02/09/22 revealed the resident had severe cognitive impairment. Review of physician's orders revealed the resident had an order for the psychoactive medication, Seroquel 50 milligrams (mg) by mouth daily for unspecified dementia, anxiety and depression and Risperdone three mg by mouth daily at bedtime for unspecified dementia. Interview with the Director of Nursing on 05/18/22 at 02:35 P.M. verified unspecified dementia 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to THE PAVILION GROUP — 6 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 52.8+1.2 vs chain
Health inspection 4 of 52.8+1.2 vs chain
Staffing 1 of 51.8-0.8 vs chain
Quality measures 5 of 54.0+1.0 vs chain
The other 5 homes this chain runs (chain average 2.8★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
PIKETON HOLDINGS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF100%since 06/01/2018
101 LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 06/01/2018
ACM ASHEM HOLDINGS, LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 06/01/2018
YDR 18 LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 06/01/2018
YP 18 LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 06/01/2018
LIEBERMAN, NECHEMIAIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 06/01/2018
KRIESER, AKIVAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 06/01/2018
RAMSEY, TARAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2018
PAVILION HEALTHCARE GROUP LLCOrganizationADP OF THE SNFsince 06/01/2018
JUSCHKA, DIRKIndividualADP OF THE SNFsince 06/01/2018
RIMBERG, RIKIIndividualADP OF THE SNFsince 06/01/2018

CMS files one row per role, so the 18 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$12.0M
Net patient revenuemost recent cost report
+4.2%
Operating marginrevenue minus expenses
$2.4M
Related-party expense21% of expenses
Who pays — share of resident-days
Medicaid 67%Medicare 12%Other / private 21%

This home reported $2.4M paid to related parties — landlords or management companies under common ownership — equal to about 21% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$384per resident / day
operating cost
$11,671per month
≈ monthly operating cost
$401per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in OH

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Ohio Medicaid page.

Typical monthly cost in Ohio
$9,186/mo
Nursing home (semi-private)
$10,389/mo
Nursing home (private)
$6,103/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 365446. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-17, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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