River Run Healthcare Of Portsmouth
1319 Spring Street, Portsmouth, OH 45662 · For profit - Limited Liability company · 25 certified beds · (740) 354-6619 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- 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
- lower-than-typical staff turnover (18% vs 45% nationally) — better care continuity
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- its payroll-based staffing rating is low (2/5)
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 | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 |
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 5 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 | 2.8% | 5.3% | 15.4% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 9.6% | 6.2% | 5.4% | worse |
| 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 | 47.6% | 30.1% | 6.5% | worse 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 | 5.7% | 3.2% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 11.2% | 6.1% | 16.1% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 61.8% | 25.5% | 18.9% | check this† — see note marked dagger below the table |
| Long-stay residents given the seasonal flu vaccine | 92.0% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.9% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 10.6% | 21.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 6.1% | 8.8% | 17.1% | better |
† This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. 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.
Staffing
How full it usually is: this home is certified for 25 beds and averages 22.2 residents a day — about 89% occupied, or roughly 3 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 3.63 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.63 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.03 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 3.58 hrs/resident/day on weekends vs 3.97 on weekdays — 10% thinner on weekends. RN hours go from 0.53 to 0.62 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 18% is below 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 unchanged from the previous inspection. 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.
12 citations, most serious first — scroll within the box to see all.
- Immediate jeopardy · J2026-05-11 · tag F0627 — isolatedEnsure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
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 hospital records, policy review, review of local police reports, staff interview, resident interview and interview with the Long-Term Care Ombudsman, the facility failed to provide a safe and proper discharge to an appropriate location for Resident #25. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries, and/or death on [DATE] when Resident #25, who had diagnoses including type two diabetes mellitus with two chronic ulcers, adult failure to thrive, functional quadriplegia, nicotine dependence, deep vein thrombosis, personality disorder, psychoactive substance abuse, anxiety, depression, and viral Hepatitis C, was discharged to an unknown location without housing, medications, or arrangements for ongoing care. Resident #25 was discharged without evidence of continuity of care related to medical care and services in place to address the resident's medical and mental health diagnoses. Resident #25 required 24-hour care for medication…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2022-05-16 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of daily staffing sheets, review of employee time clock punches and staff interview the facility failed to ensure a Registered Nurse was on-duty and present in the facility for at least eight hours daily as required. This had the potential to affect all 22 residents residing in the facility. Findings include: Review of the facility sheets titled Report of Nursing Staff Directly Responsible for Resident Care, dated 05/02/22 and 05/03/22, revealed documentation a Registered Nurse (RN) was only present for six hours each day at the facility. Review of the employee time clock punches for 05/02/22 and 05/03/22 revealed there was not an RN clocked in for work on 05/02/22 or 05/03/22. Review of the facility list provided by Business Office Manager #350 titled Agency Staffing/Hours and Other Buildings, not dated, revealed on 05/02/22 and 05/03/22 RN #805 was documented to have worked at the facility from 4:00 P.M. to 10:00 P.M. for a total of six hours each day. On 05/12/22 at 3:00 P.M. interview with the Administrator verified the facility only had an RN present in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2022-05-16 · tag F0868 — widespreadHave 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 all required members of the Quality Assessment and Assurance (QAA) committee attended meetings at least quarterly. This had the potential to affect all 22 residents residing in the facility. Findings include: Review of the QAA committee meeting minutes, dated 04/20/22 revealed the absence of the signature of the Director of Nursing (DON) to indicated the DON's presence at the meeting. On 05/12/22 at 3:00 P.M. interview with the Administrator verified the DON had not been in attendance at the QAA meeting held on 04/20/22 due to another work commitment.
- Potential for harm · D2022-05-16 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to timely initiate a significant change Minimum Dat Set (MDS) 3.0 assessment after a change in Resident #10's condition and discharge from Hospice services. This affected one resident (#10) of one resident reviewed for Hospice services. Findings include: Record review for Resident #10 revealed the resident was admitted to the facility on [DATE] and had diagnoses including altered mental status, sepsis, edema, chronic kidney disease, type two diabetes mellitus with other specified complication and acute kidney failure. Review of the admission Minimum Data Set (MDS) assessment, dated 03/18/22 revealed the resident had mildly impaired cognition with a Brief Interview for Mental Status (BIMS) score of 11 out of 15. The resident was assessed to require limited assistance from one staff member for bed mobility, extensive assistance from one staff member for transfers and limited assistance from one staff member for eating. This resident was assessed 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 · D2022-05-16 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to accurately code medications on the Minimum Data Set (MDS) 3.0 assessment for Resident #5. This affected one resident (#5) of five residents reviewed for unnecessary medication use. Findings include: Record review for Resident #5 revealed the resident was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, dementia with behavioral disturbances, anxiety and depression. Review of the admission MDS 3.0 assessment, dated 03/04/22 revealed the resident was assessed to have received an anti-psychotic medication seven of seven days in the assessment reference period. Review of the active and discontinued physician's medication orders, dated 02/25/22 through 05/10/22 revealed the resident was not prescribed any anti-psychotic medication(s). On 05/11/22 at 9:10 A.M. interview with the Director of Nursing (DON) verified Resident #5 had not received any medications classified as an anti-psychotic while residing at the facility.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-05-16 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure ongoing communication with a Hospice provider regarding the care needs and services provided to Resident #10 and failed to ensure a treatment order for Resident #16 was specific to detail the actual treatment required or being provided to the resident. This affected one resident (#10) of one resident reviewed for Hospice services and one resident (#16) of three residents reviewed for change in condition. Findings include: 1. Record review for Resident #10 revealed the resident was admitted to the facility on [DATE] and had diagnoses including altered mental status, sepsis, edema, chronic kidney disease, type two diabetes mellitus with other specified complication, and acute kidney failure. Record review revealed the resident was receiving Hospice services at the time of admission to the facility. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 03/18/22 revealed the resident had mildly impaired cognition evidenced…
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 · D2022-05-16 · 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 observation, record review, facility policy and procedure review and interview the facility failed to ensure ongoing assessments/monitoring of pressure ulcers, pressure ulcer interventions and treatments were provided for Resident #10 who was admitted to the facility with pressure ulcers. This affected one resident (#10) of two residents reviewed for pressure ulcers. Findings include: Record review for Resident #10 revealed the resident was admitted to the facility on [DATE] and had diagnoses including altered mental status, sepsis, edema, chronic kidney disease, type two diabetes mellitus with other specified complication and acute kidney failure. Review of a facility admission Nursing Observation Form, dated 03/11/22 revealed documentation the resident had pressure ulcers located on the coccyx, left heel and right heel. Review of the active physician's order, dated 03/12/22 revealed an order to cleanse the pressure ulcer to the resident's coccyx with normal saline or wound cleanser, apply Med Honey…
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 · D2022-05-16 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure appropriate indwelling urinary catheter care was provided for Resident #18 to prevent urinary tract infections when staff failed to appropriately clean the resident's catheter. This affected one resident (#18) of two residents reviewed for catheters. Findings include: Record review for Resident #18 revealed an admission date of 04/09/21 with most recent admission of 01/31/22 with diagnoses including pneumonia, depression, dysphagia, urinary tract infection, neuromuscular dysfunction of bladder, polyneuropathy, quadriplegia, cerebral infarction due to occlusion of cerebral artery, psychoactive substance abuse, bipolar disorder, nontraumatic intracranial hemorrhage, insomnia and chronic viral hepatitis C. Review of a physician's order, dated 02/09/22 revealed an order for catheter care each shift related to other neuromuscular dysfunction of the bladder. Review of the 04/09/22 annual Minimum Data Set (MDS) 3.0 assessment revealed Resident #18 was cognitively intact 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 · D2022-05-16 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide 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 and interviews the facility failed to ensure dietary recommendations were implemented and/or failed to ensure resident weights were obtained as ordered. This affected two residents (#10 and #16) of the three residents reviewed for nutrition. Findings include: 1. Record review for Resident #10 revealed the resident was admitted to the facility on [DATE] and had diagnoses including altered mental status, sepsis, edema, chronic kidney disease, type two diabetes mellitus with other specified complication and acute kidney failure. Review of the physician's orders revealed an order, dated 03/11/22 to obtain weight every day for three days after admission. Review of the care plan, dated 03/15/22 revealed the resident had protein malnutrition. Interventions included 30 milliliters (ml) of ProStat (a protein supplement) twice a day and an 1,800 ml fluid restriction. Review of the dietary progress note, dated 03/15/22 revealed a recommendation to add 30 ml of ProStat twice a day and implement an…
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 · D2022-05-16 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility policy and procedure review and interview the facility failed to timely address pharmacy recommendations for Resident #20. This affected one resident (#20) of five residents reviewed for unnecessary medication use. Findings include: Record review for Resident #20 revealed the resident was admitted to the facility on [DATE] and had diagnoses including unspecified psychosis, anxiety, major depressive disorder and insomnia. Review of the Consultant Pharmacist Recommendation for Provider, dated 07/08/21 revealed a recommendation to evaluate and consider tapering off Pantoprazole at the time. The recommendation contained no documentation of the review of the recommendation. There were no documented signature(s) by the physician or facility staff present on the recommendation. Review of the Consultant Pharmacist Recommendation for Provider, dated 09/13/21 revealed the recommendation to evaluate and consider tapering off Pantoprazole at the time. The recommendation contained no…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-05-16 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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 record review and interview the facility failed to ensure the anti-histamine medication, Vistaril (for anxiety/agitation) was administered to Resident #11 with a current physician's order to ensure the medication was necessary. This affected one resident (#11) of five residents reviewed for unnecessary medication use. Findings include: Record review for Resident #11 revealed an admission date of 02/23/22 with diagnoses including type two diabetes mellitus, altered mental status, sepsis, malignant neoplasm of prostate, dementia without behaviors, displaced intertrochanteric fracture of right femur, protein calorie malnutrition, dehydration and pneumonia. Record review revealed a physician's order, dated 04/21/22 for Vistaril (hydroxyzine pamoate), an anti-histamine medication sedative hypnotic medication 25 milligrams (mg) every eight hours as needed (PRN) for anxiety/agitation. The order for the medication was for 14 days. Review of the medication administration record Resident #11 received the Vistaril on 05/10/22 at 9:48 P.M. On 05/12/22 at 11:00 A.M. interview with the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-05-16 · 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, record review, medication insert review and interview the facility failed to maintain a medication error rate of less than five percent (%). The medication error rate was calculated to be 7.14% and included two medication errors of 28 medication administration opportunities. This affected two residents (#6 and #9) of three residents observed for medication administration. Findings include: 1. Record review for Resident #9 revealed an admission date of 10/29/19 with pertinent diagnoses of: fracture of superior rim of left pubis, overactive bladder, history of COVID-19, hypothyroidism, type two diabetes mellitus, hypertension, Alzheimer's disease, epilepsy, dementia, hyperlipidemia, Parkinson's disease, major depressive disorder, insomnia and tremor. Review of a physician's order, dated 03/31/22 revealed an order for Primidone Tablet 250 milligrams (mg) give one tablet by mouth in the morning for tremors. On 05/11/22 at 8:46 A.M. Registered Nurse (RN) #121 was observed administering medications to Resident #9. RN #121 obtained a blister pack containing 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.
- 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 HILLSTONE HEALTHCARE — 9 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 | 5 of 5 | 4.0 | +1.0 vs chain |
| Health inspection | 4 of 5 | 3.4 | +0.6 vs chain |
| Staffing | 2 of 5 | 1.8 | +0.2 vs chain |
| Quality measures | 5 of 5 | 5.0 | ≈ chain avg |
The other 8 homes this chain runs (chain average 4.0★, 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 | Since |
|---|---|---|---|
| BERRYMAN, WHITNEY | Individual | W-2 MANAGING EMPLOYEE | since 12/14/2020 |
| BERGSTEN, PAUL | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 09/01/2017 |
| DAPORE, MATTHEW | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 09/01/2017 |
| WHEATON, ANTHONY | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 09/01/2014 |
CMS files one row per role, so the 6 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
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 $173K 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 2026-09-01 — CMS provider number 365867. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-08-13, 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 →
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