Grande Pointe Healthcare Commu
Three Merit Dr, Richmond Heights, OH 44143 · For profit - Corporation · 176 certified beds · (216) 261-9600 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has abuse, neglect, or exploitation citations (F0600, F0602, F0606) — most recent Dec 2024
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (33) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $137,255 in federal fines (most recent 2024-12-17)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
- about 17% 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 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 | 4.8% | 5.3% | 15.4% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 2.3% | 6.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.2% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.2% | 0.4% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 4.0% | 30.1% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.6% | 3.2% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 6.3% | 6.1% | 16.1% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 17.9% | 25.5% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 97.4% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.5% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 15.4% | 21.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 4.9% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.3% | 1.2% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 87.6% | 75.6% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 19.8% | 24.9% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 15.2% | 12.9% | 12.0% | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
47.4% 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 61 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.18 therapist hours per resident per day in 2026Q1 — more than 17% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 13% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 47.4%CMS range 34.0–58.1 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.3%CMS range 8.7–16.7 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not 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 stay | 2.6% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 5.9%CMS range 3.1–11.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.89 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 176 beds and averages 161.3 residents a day — about 92% occupied, or roughly 15 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 3.27 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.38 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.80 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 2.90 hrs/resident/day on weekends vs 3.41 on weekdays — 15% thinner on weekends. RN hours go from 0.44 to 0.22 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 44% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
33 citations, most serious first. The 13 most serious are shown; the remaining 20 are one tap away and print in full.
- Immediate jeopardy · J2024-12-17 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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, self-reported incident (SRI) review, review of a police report, facility policy review and interviews, the facility failed to ensure Resident #28, who had dementia, was deemed incompetent, and unable to provide consent, was free from resident-to-resident sexual abuse. This resulted in Immediate Jeopardy and the potential for actual physical and psychosocial harm on 11/26/24 at approximately 8:20 P.M. when Resident #18, who had a history of engaging in physical activity (i.e. hand holding and touching behaviors) with Resident #28 without care planned interventions, was observed by Certified Nurse Aide (CNA) #396 engaged in an activity indicative of oral sex on Resident #28. This affected one resident (#28) of three residents reviewed for abuse. The facility census was 158. On 12/10/24 at 4:10 P.M., the Administrator, Director of Nursing (DON) and Regional Director of Clinical Operations (RDCO)/Registered Nurse (RN) #219 were notified Immediate Jeopardy began on 11/26/24 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2024-09-30 · 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 closed medical record review, review of skin and wound notes, facility policy review and interview, the facility failed to ensure individualized care planned interventions were developed and followed to prevent Resident #165 from developing in-house pressure ulcers within 30 days of admission and failed to ensure the pressure ulcer was properly treated, and interventions were initiated to promote healing and to prevent Resident #165 from developing an additional full thickness wound to the left buttock from incontinence associated dermatitis. Actual Harm occurred on 09/12/24 when Resident #165, who was at risk for developing pressure ulcers, was dependent on staff for bed mobility and incontinence care, and had in-house acquired Stage III pressure ulcers (full-thickness loss of skin that extended to the subcutaneous tissue, but did not cross the fascia beneath it) on her sacral area, developed a new new full thickness (extend deeper than the skin's epidermis and dermis layers and can reach 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.
- Actual harm · G2024-06-26 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility policy and interview the facility failed to develop and implement a comprehensive and effective pain management program for Resident #156, including a comprehensive pain assessment and effective interventions to timely treat the resident's pain. This affected one resident (#156) of three residents reviewed for pain. The facility census was 154. Actual Harm occurred on 04/21/24 when Resident #156, who was admitted to the facility with an unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) pressure ulcer to the sacrum, experienced moderate to severe/unbearable pain, difficulty with seated positioning, difficulty sleeping at night and pain that interfered with therapy activities and ability to complete hemodialysis treatments due to the lack of effective pain management interventions (including the administration of pain medication). Pain…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, interview, review of the facility's investigation, and facility policy review, the facility failed to provide adequate supervision to ensure a resident with moderately impaired cognition did not leave the facility without staff awareness. This affected one resident (#102) of three residents reviewed for elopements. The facility census was 162. Findings include:Review of the medical record for Resident #102 revealed an admission date of 01/20/25. Medical diagnoses included non-traumatic intracerebral hemorrhage, hypertensive chronic kidney disease, end stage renal disease, dependence on renal dialysis, anxiety, and vascular dementia without behavioral, psychotic, or mood disturbance. Review of a physician order dated 09/25/25 revealed Resident #102 was ordered a wanderguard (a wearable bracelet-like device used to monitor and prevent residents at risk for wandering…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-10-27 · 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 record review, interview, and facility policy review, the facility failed to ensure a physician order for a pressure ulcer treatment was transcribed into the electronic medical records. This affected one resident (#136) of three residents reviewed for physician orders. The facility census was 151.Findings include:Review of Resident #136 ' s medical record revealed an admission date of 02/04/25. Diagnoses included a stage four pressure ulcer (a full thickness wound involving muscle, tendon, and/or bone involvement) to the sacrum (tailbone area), stroke with right sided weakness, and malnutrition.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #136 had intact cognition. Resident #136 was dependent on staff for toileting, bathing, and personal hygiene. Review of the care plan dated 09/18/25 revealed Resident #136 had an actual skin impairment. Interventions included a negative pressure wound vac set at 125 millimeters of mercury (mmHg) of pressure and change the wound vac…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-10-27 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure appropriate infection control techniques were used during incontinence care. This affected one resident (#136) of two residents observed for incontinence care. The facility census was 151.Findings include:Review of Resident #136's medical records revealed an admission date of 02/04/25. Diagnoses included stroke with right sided weakness, muscle weakness, and malnutrition.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #136 had intact cognition. Resident #136 was dependent on staff for toileting and was incontinent of bowel and bladder.Review of the care plan dated 09/18/25 revealed Resident #136 was dependent on staff for toileting. Interventions included to check the resident for incontinence.Observation of incontinence care on 10/20/25 at 10:57 A.M. with Certified Nursing Assistant (CNA) #255 revealed Resident #136 was incontinent of liquid stool. CNA #255 had proceeded to provide Resident #136 with incontinence…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-07-10 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to complete wound treatments as ordered by the physician. This affected one resident (#114) of three residents reviewed for wound care. The facility census was 140. Findings include:Review of the medical record for Resident #114 revealed an initial admission date of 08/20/24 and re-entry date of 03/18/15. The resident had been hospitalized from [DATE] to 03/18/25 for a wound infection. Diagnoses included polyosteoarthritis, dementia, adult failure to thrive, left-hand and right-hand contractures, left and right shoulder contractures, and severe protein-calorie malnutrition.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #114 had severely impaired cognition and four venous/arterial ulcers. Review of a wound assessment report dated 03/25/25 revealed Resident #114 had a left elbow wound due to end-of-life skin failure, and arterial ulcers to the right hallux (big toe), right heel, left hallux,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-07-10 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to timely implement physician orders to insert an indwelling urinary catheter. This affected one resident (#145) of three residents reviewed for urinary tract infection (UTI) prevention. The facility census was 140.Findings include: Review of the medical record for Resident #145 revealed an admission date of 03/20/25 and discharge date of 04/01/25. Diagnoses included orthopedic aftercare, closed fracture of the lower end of left femur, closed fracture of the lateral condyle of left femur, closed fracture of the medial condyle of left femur, fracture of the ninth and tenth thoracic vertebra, and atrial fibrillation. A diagnosis of retention of urine was added upon the date of discharge on [DATE].Review of Resident #145's undated profile sheet revealed the resident was listed as his own responsible party with two children both listed as emergency contacts.Review of the nursing progress notes from 03/20/25 to 03/24/25 revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-03-11 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and review of the facility policy, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect all residents except three residents (#68, #75, and #207) who received nothing by mouth and did not receive food from the facility's kitchen. The facility census was 147. Findings include: Observations on 03/03/25 from 10:02 A.M. to 10:23 A.M. during the tour of the kitchen with Mobile Dietary Manager (MDM) #800 revealed on a rack several white dessert plates stacked that had dried brownish, substance and crumbs on several of the plates. Observation of the oven, stove, tilt skillet, and steamer all had various food crumbs and grease on the front and the surfaces on the side of the equipment. The floor in front of the stove, oven, tilt skillet, and steamer and between the stove and the tilt skillet and the tilt skillet and the steamer were dirty with a moderate amount of dark colored debris. Interview on 03/03/25 between 10:02 A.M. and 10:23 A.M. with MDM #800 verified the identified findings 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 · Ecited before2025-03-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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
Based on observation, interview, and policy review, the facility failed to ensure adequate supervision to prevent accidents related to smoking safety. This had the potential to affect four residents (#62, #85, #98, and #210) of four residents reviewed for smoking. The facility identified 18 current residents who smoked. The facility census was 147. Findings include: Observation on 03/10/25 at 9:15 A.M. of the resident smoke break with Activity Leader #548 revealed Resident #85 and Resident #98 were outside the building, approximately five feet from the glass exit door, smoking cigarettes. Activity Leader #548 was inside the building supervising through the glass door. Resident #210 arrived to smoke break late, and Activity Leader #548 opened the door for her to go out and smoke. Resident #210 wheeled herself out and parked her wheelchair with her back facing the glass door where Activity Leader #548 was supervising. Activity Leader #548 remained inside the building supervising through the door. Resident #85 was observed to pass his lit cigarette to Resident #210 to light her…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-11 · tag F0699 — isolatedProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of facility policy, the facility failed to ensure residents with a diagnosis of Post-Traumatic Stress Disorder (PTSD) were provided culturally competent and trauma-informed care. This affected two residents (#81 and #82) of two residents reviewed for PTSD. The facility census was 147. Findings include: 1. Review of Resident #81's medical record revealed the Resident was admitted to the facility on [DATE]. Her diagnoses included heart disease, burns to her head, face, and neck. Other diagnoses included major depressive disorder, scar conditions and fibrosis, insomnia, Post Traumatic Stress Disorder (PTSD), and restlessness and/or agitation. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #81 had moderately impaired cognition, slight confusion regarding person, place and time. She displayed no signs or symptoms of delirium, and no behaviors were noted. PTSD was noted as an active diagnosis. Review of Resident #81's Social History…
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 · F2024-12-17 · tag F0606 — failed to not employ staff found guilty of abuse — widespreadNot hire anyone with a finding of abuse, neglect, exploitation, or theft.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on personnel file review, interview, review of facility policies and review of the Ohio Revised Code (ORC), the facility failed to hire staff free of disqualifying offenses. This affected one out of seven personnel files reviewed and had the potential to affect all 158 residents residing in the facility. Findings include: Review of personnel files on 12/11/24 starting at 2:20 P.M. with Employee Lifecycle Manager (ELM) #246 and Regional Employee Engagement Specialist ([NAME]) #197 revealed the following area of concern: Review of Maintenance Staff (MS) #385's personnel file revealed a date of hire of 04/28/23. MS #385 was on the Bureau of Criminal Investigation (BCI) log as having a background check sent on 04/27/23 and the results returning on 05/11/23 with no findings. ELM #246 and [NAME] #197 were asked to provide the background check report. Further review of MS #385's background check report dated 05/12/23 revealed charges for domestic violence (2919.25) on 12/28/95. No personal care standards were…
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 · F2024-12-17 · tag F0607 — failed to have anti-abuse policies — widespreadDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on personnel record review, facility policy review, and interview, the facility failed to implement their abuse policy and procedure regarding checking potential applicants against the Ohio Nurse Aide Registry (NAR) prior to working with residents as well as completing background checks as required. This affected six out of seven personnel files reviewed and had the potential to affect all 158 residents who resided in the facility. Findings include: Review of personnel files on 12/11/24 starting at 2:20 P.M. with Employee Lifecycle Manager (ELM) #246 and Regional Employee Engagement Specialist ([NAME]) #197 revealed the following areas of concern: • Review of Certified Nurse Aide (CNA) #365's personnel file revealed a date of hire of 11/29/23. CNA #365 was checked against the NAR on 12/19/23, after she had already been working with residents. CNA #365 was not on the facility's background check log and her file contained no envelope with background checks available for further review. • Review of Dietary…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 20 citations
- Potential for harm · E2024-12-17 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
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 the facility assessment, self-reported incident (SRI) review and interview the facility failed to maintain sufficient levels of staff on the secured care unit to meet the supervisory needs of all residents. This affected two residents (#18 and #28) and had the potential to affect the 41 residents residing on the facility's secured memory care unit. Facility census was 158. Findings include: Review of the facility assessment dated [DATE] revealed based on the facility resident population and their needs for care and support, our approach to staffing is to ensure that each of our nursing facility residents has the minimum direct care staff to meet the needs of the residents at any given time. We work to assure necessary staff based on the model shown. For the Connections (secured) unit on night shift, there were to be one to two licensed nurses and two to three nurse aides. The facility assessment did not delineate what would determine more or less nurses or aides or at what point…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-17 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of a self-reported incident (SRI), review of facility policies and interview, the facility failed to timely inform residents' attending physicians of an instance of resident-to-resident sexual abuse. This affected two residents (Resident #18 and Resident #28) out of three residents reviewed for abuse. Facility census was 158. Findings include: 1. Review of Resident #28's medical record revealed an admission date of 10/19/19 and diagnoses including heart disease, vascular dementia with other behavioral disturbance, depression, cognitive communication deficit, insomnia, post-traumatic stress disorder (PTSD), dysphagia, burn of unspecified degree of head, face and neck restlessness and agitation. Review of Resident #28's guardianship documentation revealed she was deemed incompetent and had a guardian of person effective 03/13/20. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 had a brief interview for mental status (BIMS) score of nine,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-17 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, review of a self-reported incident (SRI), review of the facility investigation and review of the facility policy, the facility failed to thoroughly investigate allegations of resident-to-resident sexual abuse. This affected one resident (#28) of three residents reviewed for abuse. Facility census was 158. Findings include: Review of Resident #28's medical record revealed an admission date of 10/19/19 with diagnoses including heart disease, vascular dementia with other behavioral disturbance, depression, cognitive communication deficit, insomnia, post-traumatic stress disorder (PTSD), dysphagia, burn of unspecified degree of head, face and neck restlessness and agitation. Review of Resident #28's guardianship documentation revealed she was deemed incompetent and had a guardian of person effective 03/13/20. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 had a brief interview for mental status (BIMS) score of nine, indicating moderate cognitive…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, fall investigation review, interview and review of the facility policy, the facility failed to thoroughly investigate falls to ensure appropriate safety interventions were in place for Resident #160. This affected one resident (#160) of three residents reviewed for falls. Facility census was 158. Findings include: Review of Resident #160's closed medical record revealed an admission date of 09/04/24 and diagnoses including type two diabetes, repeated falls, hypertension, obesity, aphasia following cerebral infarction and hemiplegia and hemiparesis following non-traumatic intracerebral hemorrhage affecting left non-dominant side. Resident #160 discharged to the hospital on [DATE] and did not return to the facility. Review of Resident #160's physician's orders revealed an order dated 09/04/24 for low bed with bilateral mats to floor every shift and an order dated 09/04/24 for physical therapy (PT) and occupational therapy (OT) to evaluate. Review of Resident #160's admission nursing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-09-30 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of the facility policy the facility failed to ensure Resident's #28 and Resident#127 were provided incontinence care timely. This affected two residents (Resident's #28 and #127) out of four residents reviewed for incontinence care. The facility census was 160. Findings include: 1. Review of Resident #28's medical record revealed an admission date of 09/30/20 and diagnoses included Alzheimer's Disease, vascular dementia, and other speech and language deficits following unspecified cerebrovascular disease. Review of Resident #28's care plan dated 10/20/21 and revised on 08/07/24 included Resident #28 was incontinent of bowel and bladder related to impaired cognition, impaired mobility. Resident #28 would remain free of skin break down due to incontinence. Interventions included to check Resident #28 for incontinence and wash, rinse and dry perineum, and changed clothing as needed after incontinence episodes; Resident #28 used disposable briefs, change as…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-30 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review and review of the facility policy the facility failed to ensure a medication error rate of less than 5 percent (%). A Total of two errors out of 26 opportunities were observed resulting in a 7.69% medication error rate. This affected two residents (Resident's #98 and #139) out of six residents reviewed for medication administration. The facility census was 160. Findings include: 1. Review of Resident #98's medical record revealed an admission date of 01/04/24 and a re-entry date of 09/10/24. Resident #98's diagnoses included chronic respiratory failure, chronic obstructive pulmonary disease, and dependence on renal dialysis. Review of Resident #98's physician orders dated 09/11/24 at 12:17 A.M. revealed orders for Spiriva Respimat 2.5 mcg/ACT Aerosol, solution, two puffs inhale orally in the morning for COPD (chronic obstructive pulmonary disease). Observation on 09/25/24 at 8:38 A.M. of Licensed Practical Nurse (LPN) #821 revealed she was standing at the medication cart preparing medications for Resident #98. LPN #821 prepared…
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 · E2024-07-10 · tag F0602 — failed to protect residents from theft of their belongings — patternProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on medical record review, review of a facility self-reported incident (SRI) investigation, observation, staff and resident interviews, and review of the facility Abuse, Neglect and Misappropriation policy, the facility failed to ensure controlled substances were stored and discarded properly to prevent misappropriation. This affected seven residents (#256, #257, #258, #259, #260, #261, and #262) of seven residents reviewed for misappropriation. The facility census was 156. Findings include: Review of the closed medical record for Resident #256 revealed an admission date of 04/21/24 and a discharge date of 05/01/24. Diagnoses included but were not limited to sepsis, type II diabetes with polyneuropathy and chronic kidney disease. Review of Resident #256's physician orders dated 04/26/24 revealed an order for Percocet (oxycodone) oral tablet 5-325 milligrams (mg). Give one tablet by mouth every morning and at bedtime for moderate pain. Review of the closed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-26 · 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 record review, interview, and review of the facility policy the facility failed to ensure care planned interventions were timely implemented for treatments for Resident #156's unstageable sacral pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed). This affected one resident (#156) out of three residents reviewed for wounds. The facility census was 154. Findings include: Review of Resident #156's medical record revealed an admission date of 04/21/24 with diagnoses including sepsis, pneumonia, type two diabetes mellitus with diabetic chronic kidney disease, and diabetic polyneuropathy. Resident #156 had dependence on renal dialysis. Resident #156 was discharged from the facility to another skilled nursing facility on 05/01/24. Review of Resident #156's After Visit Summary and Clinical Summary dated 04/06/24 through 04/21/24 included Resident #156 was admitted to the hospital…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and review of the facility policy the facility failed to ensure Resident #156 had individualized care planned interventions for falls, failed to ensure a thorough investigation and accurate follow up evaluation after a fall. This affected one resident (#156) out of three residents reviewed for accidents. The facility census was 154. Findings include: Review of Resident #156's medical record revealed an admission date of 04/21/24 with diagnoses including sepsis, pneumonia, type two diabetes mellitus with diabetic chronic kidney disease and diabetic polyneuropathy. Resident #156 had dependence on renal dialysis. Resident #156 was discharged from the facility to another skilled nursing facility on 05/01/24. Review of Resident #156's After Visit Summary and Clinical Summary dated 04/06/24 through 04/21/24 included Resident #156 was admitted to the hospital with diabetic ketoacidosis without coma associated with other specified diabetes mellitus, end stage renal disease, Influenza A, pneumonia of both lungs due to infectious organism, unspecified part…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-26 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility policy the facility failed to ensure Resident #156 received dialysis on his scheduled days per physician orders. This affected one resident (#156) out of three residents reviewed for dialysis. The facility census was 154. Findings include: Review of Resident #156's medical record revealed an admission date of 04/21/24 with diagnoses including sepsis, pneumonia, type two diabetes mellitus with diabetic chronic kidney disease, and diabetic polyneuropathy. Resident #156 had dependence on renal dialysis. Resident #156 was discharged from the facility to another skilled nursing facility on 05/01/24. Review of Resident #156's After Visit Summary and Clinical Summary dated 04/06/24 through 04/21/24 included Resident #156 was admitted to the hospital with diabetic ketoacidosis without coma associated with other specified diabetes mellitus, end stage renal disease, Influenza A, pneumonia of both lungs due to infectious organism, unspecified part of lung, 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 · D2024-06-26 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility policy the facility failed to ensure Resident #156 received medications per physician orders. This affected one resident (#156) out of three residents reviewed for medication administration. The facility census was 154. Findings include: Review of Resident #156's medical record revealed an admission date of 04/21/24 with diagnoses including sepsis, pneumonia, type two diabetes mellitus with diabetic chronic kidney disease and diabetic polyneuropathy. Resident #156 had dependence on renal dialysis. Resident #156 was discharged from the facility to another skilled nursing facility on 05/01/24. Review of Resident #156's After Visit Summary and Clinical Summary dated 04/06/24 through 04/21/24 included Resident #156 was admitted to the hospital with diabetic ketoacidosis without coma associated with other specified diabetes mellitus, end stage renal disease, Influenza A, pneumonia of both lungs due to infectious organism, unspecified part of lung, 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 · Dcited before2024-05-21 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, record review, and review of facility policy the facility did not ensure Resident #131 was provided timely incontinence care. This affected one resident (#131) out of three residents reviewed for incontinence. This had the potential to affect 102 residents (#2, #3, #4, #5, #7, #11, #12, #13, #14, #15, #17, #19, #20, #22, #23, #25, #26, #27, #28, #29, #30, #32, #33, #36, #37, #38, #39, #40, #41, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #57, #59, #62, #64, #65, #66, #68, #70, #71, #72, #73, #74, #76, #77, #79, #80, #81, #82, #83, #84, #86, #87, #88, #91, #92, #93, #96, #97, #103, #104, #105, #107, #108, #110, #112, #114, #115, #117, #118, #119, #120, #121, #123, #125, #126, #127, #128, #131, #132, #133, #134, #135, #136, #137, #138, #139, #140, #142, #144, #145, #146, and #148) that were identified by the facility as incontinent. The facility census was 142. Findings include: Review of the medical record for Resident #131 revealed an admission date 04/29/24 with…
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 · D2022-07-21 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, interview, and observation the facility failed to provide residents who received meals in their rooms the opportunity to choose menu items prior to meal service and failed to ensure a copy of the menus and the always available meal alternatives were posted in an easily accessible location. This affected two (Resident's #16 and #67) of five residents reviews for choices. The facility census was 156. Findings include: Review of the medical record for Resident #16 revealed an admission date of 06/04/18. Diagnoses included chronic obstructive respiratory failure, chronic obstructive pulmonary disease, and diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/12/22, revealed Resident #16 had intact cognition. Review of the medical record for Resident #67 revealed an admission date of 05/03/22. Diagnoses included dementia, type two diabetes mellitus, and chronic kidney disease. Review of the quarterly MDS 3.0 assessment, dated 07/12/22, revealed Resident #67 had impaired cognition. Interviews on 07/18/22 at 10:40 A.M.,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-07-21 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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 — the official record, unedited, may be distressing
Based on record review, observations, and interviews the facility failed to change dirty bed linens in a timely manner. This affected one (Resident #22) of five residents reviewed for environment. The facility census was 156. Findings include: Review of medical record revealed Resident #22 had an admission date of 12/18/20. Diagnoses included Wernicke's encephalopathy, cognitive communication deficit, and abnormalities of gait and mobility. Observation on 07/18/22 at 10:30 A.M. revealed bed linens for Resident #22 were covered with brown material covering the lower half of the bed. The bed linens were piled up on the bed, the pillow was broken down and cracked and had no pillowcase. Resident #22 verified the observation. Observation on 07/19/22 at 8:25 A.M. revealed Resident #22's bed linens were not changed; the blankets were in the same position, and the pillow didn't have a pillowcase on it. Interview on 07/19/22 at 8:30 A.M., Licensed Practical Nurse (LPN) #602 and Resident #22 verified the observations. LPN #602 changed the linens and made the bed.
- Potential for harm · D2022-07-21 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observations, and interviews the facility failed to provide activities for Resident #104. This affected one (Resident #104) of five residents reviewed for activities. The facility census was 156. Findings include: Review of the medical record for Resident #104 revealed an admission date of 01/04/19. Diagnoses included chronic obstructive pulmonary disease, abnormalities of gait and mobility, contracture to the left and right hip, and left and right knee. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/13/22, revealed Resident #104 had impaired cognition. The resident required extensive assistance for bed mobility, transfers, and ambulation. Review of the plan of care dated 02/01/22 revealed Resident #104 had impaired cognitive function, dementia with short term memory loss. Intervention included to provide a program of activities to accommodate the resident's abilities. Review of the Activity Preference Interview dated 02/23/22 revealed Resident #104 currently interested in audio books/reading/writing, crafts/arts, sports, music,…
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 · D2022-07-21 · 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 observation, interview, and record review the facility failed to ensure adequate feeding assistance. This affected one resident (Resident #356) of one resident observed for feeding assistance. The facility census was 156. Findings include: Review of the medical record for Resident #356 revealed an admission date of 07/03/22. Diagnosis included dementia, cognitive deficits, and dysphasia (difficulty swallowing). Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed no recorded cognitive score due to Resident #356 was rarely understood. Resident #356 required extensive assistance with eating, toileting, and personal hygiene. Review of the care plan dated 07/06/22 revealed Resident #356 had cognitive deficits and required assistance of one staff for eating. Resident #356 was at risk for aspiration due to dysphasia and required assistance with meals. Interview on 07/18/22 at 11:36 A.M. with Resident #356's daughter revealed the resident was unable to eat or drink on her own and she…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-07-21 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide appropriate dialysis care. This affected three (Resident's #25, #131, #135) of three reviewed for dialysis care. The facility census was 156. Findings include: 1. Review of the medical record for Resident #25 revealed an admission date of 07/20/22. Diagnosis included end stage renal disease (ESRD) and dialysis dependence. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #25 had intact cognition and required extensive assistance with transfers, toileting, and personal hygiene. Review of the care plan dated 07/11/22 revealed Resident #25 was currently on dialysis therapy related to ESRD, and dialysis was to be done Monday, Wednesday, and Friday with a pickup time of 5:50 A.M. and ensure Resident #25 was up by 5:00 A.M. Review of the current physician's orders for July 2022 revealed Resident #25 was to be up at 5:00 A.M. on dialysis days and was to be picked up at 5:50 A.M. for dialysis, and a pre/post dialysis…
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 · Fcited before2019-05-18 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure proper sanitation procedures of resident unit pantries. This had the potential to effect 162 of 171 residents who ate by mouth. Nine Residents (#1, #4, #16, #24, #67, #86, #109, #116 and #464) received enteral nutrition. Findings include: Observation of pantries on 05/13/19 from 1:33 P.M. through 1:45 P.M. located on each unit revealed that all four microwaves located in the pantries used to warm resident's food had residue and food splatter on the inside, this was verified by Dietary Manager #99. On the [NAME] Skilled pantry, the small refrigerator that snacks and extra drinks were kept in had a ripped gasket that had accumulated food particles and juice in it. This was verified by Dietary Manager #99 at 1:35 P.M. Interview with Dietary Manager #99 on 05/13/19 revealed housekeeping was responsible for cleaning microwaves and dietary was responsible for cleaning refrigerators. There was no policy or schedule for maintaining refrigerators located…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-05-18 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy and procedure review, the facility failed to identify and provide needed care and resident centered services, in accordance with the professional standards of practice to meet the needs of Residents #1 and #43. This affected one (Resident #1) of one resident reviewed for position/mobility and one (Resident #43) of three residents reviewed for activities of daily living. Findings include: 1. Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] with diagnoses including chronic heart failure, chronic kidney disease, osteoarthritis, cognitive communication deficit and obesity. Review of physician's orders dated 10/11/18 indicated she was to be provided a restorative dressing/grooming program with supervision to limited assistance for lower body for a minimum of 15 minutes daily, six to seven days per week. Review of the shower/bathing preferences dated 10/18/17 indicated she preferred a shower. Review of the plan of care…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2019-05-18 · tag F0623 — widespreadProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to notify the long-term care ombudsman of resident transfers to the hospital within 30 days. This affected four of four residents (Residents #11, #44, #107, and #129) reviewed for transfer and discharge. Findings include: 1. Clinical record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses that included vascular dementia, generalized muscle weakness, blindness right eye, and history of cerebral infarction. On 05/02/19 Resident #11 sustained a fall and was transferred to the hospital on [DATE]. There was no documentation to indicate the the State Ombudsman was notified of the discharge to the hospital. 2. Resident #59 was admitted to the hospital directly from an orthopedic appointment on 02/14/19 for possible amputation. There was no documentation to indicate the the State Ombudsman was notified of the discharge to the hospital. 3. Resident #129 was admitted to the hospital from the dialysis unit on 03/17/19 due 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$137,255 in federal fines across 3 penalties.
- $93,152 — penalty dated 2024-12-17
- $22,425 — penalty dated 2024-09-30
- $21,678 — penalty dated 2024-06-26
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to COMMUNICARE HEALTH — 110 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 | 2 of 5 | 3.2 | -1.2 vs chain |
| Health inspection | 2 of 5 | 2.7 | -0.7 vs chain |
| Staffing | 2 of 5 | 2.6 | -0.6 vs chain |
| Quality measures | 4 of 5 | 4.5 | -0.5 vs chain |
The other 109 homes this chain runs (chain average 3.2★, per CMS)
Showing 40 of 109; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| THIRD OPTION OP CO., LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 05/01/2020 |
| OPTION HOLDINGS III, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 05/01/2020 |
| THE STEPHEN L. ROSEDALE 2012 SPOUSAL TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 12/16/2005 |
| ROMEO, DOMINIC | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 04/01/2023 |
| STOLTZ, CHARLES | Individual | CORPORATE OFFICER | — | since 12/16/2005 |
| WILHEIM, RONALD | Individual | CORPORATE OFFICER | — | since 12/16/2005 |
| MERIT OHIO MGT CO LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/19/2025 |
| BALAJI, HARIGOPAL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/01/2012 |
| EDDY, GENE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/29/2024 |
| GROVES, DONNA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 04/14/2023 |
| C R STOLTZ II LLC | Organization | ADP OF THE SNF | — | since 12/16/2005 |
| C.R. STOLTZ IRREVOCABLE TRUST | Organization | ADP OF THE SNF | — | since 12/16/2005 |
| I. ROSEDALE IRREVOCABLE TRUST | Organization | ADP OF THE SNF | — | since 12/16/2005 |
| R.S. WILHEIM IRREVOCABLE TRUST | Organization | ADP OF THE SNF | — | since 12/16/2005 |
| RONALD S WILHEIM 2012 SPOUSAL TRUST | Organization | ADP OF THE SNF | — | since 12/16/2005 |
| ROSEDALE FAMILY INVESTMENT COMPANY, INC | Organization | ADP OF THE SNF | — | since 12/16/2005 |
| RRW, LLC | Organization | ADP OF THE SNF | — | since 12/16/2005 |
| S.L. ROSEDALE IRREVOCABLE TRUST | Organization | ADP OF THE SNF | — | since 12/16/2005 |
| WILHEIM FAMILY INVESTMENT COMPANY, INC. | Organization | ADP OF THE SNF | — | since 12/16/2005 |
CMS files one row per role, so the 25 rows in the source record cover these 19 parties — each is shown once here with every role it holds. Nothing is omitted.
13 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.
About 80% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $2.5M paid to related parties — landlords or management companies under common ownership — equal to about 17% 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 2024. 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, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OH
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Ohio Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 366008. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-11, 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.