Normandy Manor Of Rocky River
22709 Lake Rd, Rocky River, OH 44116 · For profit - Limited Liability company · 150 certified beds · (440) 333-5400 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Nov 2024
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0569)
- it has 1 actual-harm citation
- a high number of inspection citations overall (32) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 3 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
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 |
| 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 1 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 | 2.3% | 5.3% | 15.4% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 6.1% | 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 | 0.6% | 0.4% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.0% | 30.1% | 6.5% | check this* — see note marked star 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 | 4.6% | 3.2% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 3.9% | 6.1% | 16.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 37.8% | 25.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 98.4% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.7% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 26.1% | 21.4% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 7.1% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 88.4% | 75.6% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 30.0% | 24.9% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 8.5% | 12.9% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.46 | 1.73 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.59 | 1.80 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
53.7% 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 92 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 45.2% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 42 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.30 therapist hours per resident per day in 2026Q1 — more than 49% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 12% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 53.7%CMS range 42.8–63.8 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.6%CMS range 7.1–15.5 | 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 | 45.2% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 33.3% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 19.1% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 90.4% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.9% | 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 | 1.9% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.0%CMS range 3.8–12.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.88 | 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 150 beds and averages 132.8 residents a day — about 89% occupied, or roughly 17 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 3.55 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.39 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.24 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 3.18 hrs/resident/day on weekends vs 3.70 on weekdays — 14% thinner on weekends. RN hours go from 0.46 to 0.21 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
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.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
32 citations, most serious first. The 11 most serious are shown; the remaining 21 are one tap away and print in full.
- Actual harm · G2024-02-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record reviews, observations, family interview, staff interviews, and policy review the facility failed to ensure adequate fall interventions were in place to promote resident safety and prevent falls. Actual harm occurred on 12/05/23 when Resident #120, who was severely cognitively impaired and assessed at risk for falls, sustained an unwitnessed fall from a bed that was not in low position resulting in increased pain and hospitalization for traumatic sacral fractures with presacral edema and lumbar one and four compression fractures. The resident was not a candidate for invasive procedures and returned to the facility with hospice consultation orders. This affected three residents (#2, #88 and #120) of three residents reviewed for falls. The facility census was 117. Findings include: 1. Review of Resident #120's medical record revealed an admission date of 12/19/22, a re-admission date of 12/08/23 and a discharge date of 12/15/23. Diagnosis included unspecified dementia, chronic atrial…
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 · E2024-11-06 · tag F0558 — failed to accommodate residents' needs and preferences — patternReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident record review, resident and family interviews, staff interviews, facility policy review, call light audit review, resident council meeting minutes review, and concern log review, the facility failed to ensure call lights were in reach for two residents (#31, #62) and also failed to ensure call lights were answered in a timely manner for eighteen residents (#6, #17, #20, #24, #27, #60, #61, #65, #68, #72, #89, #92, #94, #101, #110, #127, #133, #136). This had the potential to affect all residents residing in the facility. The facility census was 136. Findings include: 1. Review of the medical record for Resident #65 revealed she was admitted to the facility on [DATE] with diagnoses including sepsis, hyperlipidemia, and atherosclerotic heart disease. Review of the physician orders revealed an order to encourage Resident #65 to reposition dated 10/04/24 and an order dated 10/08/24 for hoyer lift transfers at all times. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE]…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-11-06 · tag F0600 — failed to protect residents from abuse and neglect — patternProtect 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
Based on record review, staff interviews and review of the employee handbook, the facility failed to ensure staff did not neglect resident care due to staff sleeping while on duty. This had the potential to affect all twenty-two residents (#3, #12, #14, #15, #20, #34, #43, #46, #51, #53, #55, #57, #64, #70, #79, #116, #119, #123, #124, #128, #131, #134) residing on the 500-Hall and had the potential to affect all twenty-three residents (#8, #9, #16, #17, #26, #31, #39, #47, #58, #59, #68, #72, #80, #85, #86, #88, #97, #103, #106, #117, #125, #127, #133,) residing on the 800-Hall. The facility census was 136. Findings include: Review of the resident council meeting minutes dated 09/25/24 revealed an identified concern by Resident #17 regarding staff sleeping outside of his room with blankets. Resident #17 resided on the 800-Hall. Review of the facility Employee Handbook effective 05/01/16 revealed the facility had in place requirements of its staff to promote efficiency, productivity, and cooperation. Review of the handbook, page 28 and 29, revealed prohibited actions that would…
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 · D2024-11-06 · 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 and interview, the facility failed to timely notify Resident #146's physician or nurse practitioner (NP) regarding the resident's decreased oral intake. This affected one resident (#146) of three residents reviewed for notification of change. The facility census was 136. Findings include: Review of Resident #146's medical record revealed the resident was admitted on [DATE] and discharged on 10/07/24 with diagnoses including cerebral infarction, unspecified dementia, hypothyroidism and major depressive disorder. Review of Resident #146's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment; the resident had not had a weight loss or weight gain. Review of Resident #146's weight tracking form revealed on 05/02/24 the resident weighed 147.8 pounds in a wheelchair and on 09/05/24 the resident weighed 148 pounds in a wheelchair. Review of Resident #146's physician orders revealed an order dated 04/24/24 (discontinued 05/20/24)…
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 before2024-08-22 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, resident interview, staff interview, medical record review and review of facility policy, the facility failed to ensure Enhanced Barrier Precautions (EBP) were consistently implemented for Resident #67. This affected one (#67) of one resident reviewed for EPB. The facility identified 27 additional residents (#2, #9, #12, #14, #16, #27, #32, #33, #36, #44, #50, #54, #59, #60, #63, #76, #79, #80, #82, #101, #105, #107, #108, #118, #123, #126, and #127) on EBP. Additionally, the facility failed to ensure hand hygiene was performed following resident care. This affected two (#73 and #85) of two residents reviewed for personal care. The facility census was 127. Findings include: Record review for Resident #67 revealed an admission date of 05/31/24. Diagnoses included gastrostomy status. Review of the admission Minimum Data Set (MDS) assessment, dated 06/07/24, revealed Resident #67 was cognitively intact. Resident #67 was dependent for toileting, bathing, personal hygiene and was always incontinent of bowel and bladder. Resident #67 had medically complex conditions…
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 before2024-07-11 · tag F0814 — failed to dispose of garbage properly — widespreadDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, and review of the facility policy, the facility failed to maintain a clean and sanitary dumpster area. This had the potential to affect all of the residents residing in the facility. The facility census was 126 residents. Findings include: Observation on 07/08/24 at 9:02 A.M. with Dietary Director (DD) #470 of facility dumpster area behind the kitchen revealed there were two dumpsters. The sliding doors on the sides of both dumpsters were open with a significant amount of garbage and debris on the ground outside the dumpsters and in the surrounding brush. There was an unpleasant odor emanating from the dumpster. Interview on 07/08/24 at 9:03 A.M. with DD#470 confirmed maintaining the dumpster area was a shared responsibility with grounds and kitchen staff. DD#470 confirmed the dumpster area was not maintained in a clean and sanitary manner. Review of facility policy titled Garbage Removal and Dumpster undated revealed the dumpster would have a tight fitting lid and slide doors and would be kept covered at all times. This deficiency represents…
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 · E2024-07-11 · tag F0655 — patternCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure baseline care plans were developed and failed to ensure summaries of the baseline care plan were provided to the residents and/or their representatives. This affected two (Residents #120 and #67) out two residents who were reviewed for baseline care plans. The facility census was 126 residents. Findings include: 1. Review of the medical record for Resident #120 revealed admission date of 05/25/24 and diagnoses including sepsis due to streptococcus pneumoniae, aphasia, and dysarthria. Review of the admission Minimum Data Set (MDS) assessment for Resident #120 dated 06/01/24 revealed the resident had severely impaired cognition and was dependent on staff for activities of daily living (ADLs.) Review of the medical record for Resident #120 revealed it did not include a baseline care plan. Interview on 07/11/24 at 1:04 P.M. with MDS Nurse #508 confirmed the facility had not completed a baseline care plan…
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 · D2024-07-11 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure physician's orders were followed regarding dressing changes for an enteral tube feeding site. This affected one (Resident #67) of one reviewed for enteral nutrition. The facility identified two Residents (#67 and #378) as receiving enteral nutrition feedings. The facility census was 126 residents. Findings include: Review of the medical record for Resident #67 revealed an admission date of 05/31/24 with diagnoses including left non-dominant sided hemiplegia and hemiparesis, cerebral infarction, difficulty walking, dysphagia, gastrostomy status, aphasia, and enterocolitis due to clostridium difficile. Review of the physician's orders for Resident #67 revealed an order dated 06/01/24 revealed the resident to receive nothing by mouth (NPO) and was to receive continuous enteral feeding to meet nutrition and hydration needs. Review of the physician's order dated 06/13/24 revealed Resident #67's percutaneous endoscopic gastrostomy (PEG) tube…
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 · F2024-02-12 · tag F0583 — failed to protect personal privacy — widespreadKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, resident interview, Ombudsman interview, and staff interviews, the facility failed to deliver all of residents mail to them and or their authorized representative. The facility also failed to provide residents mail to them unopened. This affected five (#10, #36, #97, #122, and #123) of five reviewed for mail and had the potential to affect all residents. The facility census was 117. Findings include: 1. Review for Resident #97's medical record revealed an admission date of 05/05/23. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #97 revealed Resident #97 was cognitively intact. Interview on 02/06/24 at 3:04 P.M., with Resident #97 revealed she received her mail the previous day delivered by an Activities Assistant #262. Resident #97 revealed she received four envelopes of mail and one of the envelopes was opened prior to her receiving it. Resident #97 grabbed the four envelopes. One of the four envelopes were opened. The envelope opened had Resident #97's full name on the top line of the envelope. Under her name was 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 · D2024-02-12 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident interview, Ombudsman interview and staff interview, the facility failed to provide timely monthly billing statements to a resident for care and services. This affected one (#97) of three residents reviewed for monthly billing statements. The facility census was 117. Findings include: Review of Resident #97's medical record revealed an admission date of 05/05/23. Record review of diagnoses included congestive heart failure and collapsed vertebrae. Record review of the census form revealed from 06/09/23 through 09/20/23 Resident #97 was private pay. Resident #97 had a hospital stay from 09/20/23 and returned to the facility on [DATE] under Managed Care. On 12/04/23, Resident #97 was again private pay. Review of the quarterly Minimum Data Set (MDS) for Resident #97 revealed Resident #97 was cognitively intact. Resident #97 had no impairment of upper or lower extremities. Resident used a wheelchair for mobility. Review of the form titled, Rescinded 30-day discharge for (Resident #97)…
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 · D2024-02-12 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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, family interview, staff interview, and policy review, the failed to update to care plans to included fall interventions. This affected three (#2, #88, and #120) of three resident reviewed for care plans. The facility census was 117. Findings included: 1. Review of Resident #120's medical record revealed an admission date of 12/19/22, a re-admission date of 12/08/23 and a discharge date of 12/15/23. Diagnosis included unspecified dementia, chronic atrial fibrillation, difficulty in walking, muscle weakness, need for assistants with personal care, and cognitive communication deficit. Record review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #120 was severely cognitively impaired. Review of the Morse Fall Scale completed on 12/19/22, 01/02/23, 01/13/23, 04/18/23, and 07/19/23 revealed Resident #120 was at high risk for falls. Review of the Morse Fall Scale completed on 10/21/23 revealed Resident #120 was a moderate risk for falls and review of the Morse…
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 21 citations
- Potential for harm · Fcited before2023-12-19 · 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 policy review, the facility failed to ensure foods were labeled, dated and not retained when expired. This had the potential to affect 118 residents receiving food from the facility's kitchen as Resident #13 was ordered nothing-by-mouth (NPO). The facility census was 119 residents. Findings include: Observation of the unit refrigerators on 12/14/23 starting at 10:23 A.M. with Dietary Manager (DM) #263 revealed the following areas of concern: • In the east dining room refrigerator, a bag with Resident #17's name on it had a sell by date of 10/01/23 and contained bread and soup. There was a container with Resident #23's name on it that had no date and contained salad and pita bread. There was a pizza box labeled with Resident #4's name and the date 12/03/23. There was a pie with no name or date and another pizza with no name or date. On the door of the refrigerator, a sign in bright pink stated, RESIDENT FOOD ITEMS ONLY. All items must be dated. Discard all items after 72 hours once opened. An additional sign in bright orange dated 05/02/19 read,…
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 before2022-04-15 · 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 record review the facility failed to ensure the high temperature dish machine reached the minimum rinse temperature required to ensure appropriate sanitation of dishes and utensils. This had the potential to affect 87 residents receiving meals from the kitchen (Resident #345 was ordered nothing-by-mouth). The facility census was 88. Findings include: Observation on 04/11/22 at 8:57 A.M. of the facility's dish machine with Dietary Manager (DM) #546 revealed the machine was in use. There were two indicator gauges for the wash and rinse cycle water temperatures, and both read 90 degrees Fahrenheit (F). Dish machine temperature logs were posted to the left of the dish machine. Review of the April 2022 dish machine temperature logs revealed temperatures were taken at breakfast, lunch, and dinner meals. Data through 04/11/22 at the breakfast meal revealed final rinse temperatures were as follows: • 04/01/22 150 degrees Fahrenheit (F), breakfast; 149 degrees F, lunch; 150 degrees F, dinner • 04/02/22 155 degrees F, breakfast; 155 degrees F, lunch; 150…
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 before2022-04-15 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, facility policy review, and review of the Centers for Disease Control (CDC) Considerations for Preventing Spread of Covid-19, the facility failed to maintain proper infection control procedures to prevent the spread of infection. This had the potential to affect all residents residing in the facility. In addition, the facility failed to properly clean a shared glucometer between residents. This affected two (Resident's #79 and #64) of two residents reviewed for blood glucose monitoring. The facility census was 88. Findings include: 1. Review of Resident #248's medical records revealed an admission date of 04/11/22 with diagnoses including stroke, kidney failure, and sickle cell. Review of Resident #248's immunizations revealed no evidence of a Covid-19 vaccination. Review of the physician orders dated 04/11/22 revealed Resident #248 was ordered to be placed on isolation precautions for ten days upon admission. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE]…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-04-15 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and facility policy review, the facility failed to ensure medication stored in the medication carts were not expired and insulin vials were labeled with the date opened. This affected nine residents (Resident #21, #24, #35, #39, #54, #64, #86, #87, and #245) and had the potential to affect all 88 residents residing in the facility. Findings include: Observation on 04/12/22 at 3:03 P.M. of the medication cart in the 800 hall revealed the following: 1. Humalog insulin Kwik pen labeled only with room number for Resident #24 and an open date of 03/22/21 2. Lantus Solostar insulin 100 units per milliliter (u/ml) for Resident #64 was opened with an unreadable date on bottle 3. Vial of Humalog insulin 100 u/ml for Resident #54 was not labeled with date opened. A date of 03/27/22 was only on the opened box without a lid 4. Vial of Humalog insulin 100 u/ml for Resident #39 was not labeled with date opened. A date of 03/20/22 was only on the opened box without a lid 5. Vial of Lantus insulin 100 u/ml for Resident #39 was not labeled with date opened. A date of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-04-15 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of 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 observation, interview, and review of the facility's menu spreadsheet the facility failed to serve portions as specified on the menu spreadsheet. This affected 27 residents including 19 residents on a mechanical soft diet (Residents #9, #13, #15, #18, #22, #33, #49, #55, #59, #65, #68, #73, #77, #78, #85, #88, #91, #246 and #445) and eight residents on a pureed diet (Residents #27, #34, #37, #44, #47, #56, #72 and #74). The facility census was 88 residents. Findings include: Review of the menu spreadsheet for 04/12/22 for the lunch meal revealed a meal consisting of chicken, potatoes au gratin, California blend vegetables, and mint chocolate chip ice cream with alternates listed as pork roast, gravy, sweet potatoes, and Prince [NAME] vegetable mix. Portions for the chicken included three ounces for regular consistency diets, a #10-scoop for mechanical soft chicken, and a #10-scoop for pureed chicken. Observation of tray line on 04/12/22 starting at 11:27 A.M. revealed a lunch meal consisting of chicken,…
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 · D2022-04-15 · tag F0569 — isolatedNotify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure resident funds were disbursed in a timely manner for Resident #94 after death as required, and failed to provide a spend-down letter for Resident #6 when she was over the resource limit. This affected two residents (Resident #6 and Resident #94) of five residents reviewed for resident funds. The facility census was 88 residents. Findings include: 1. Review of Resident #94's closed medical record revealed an admission date of [DATE] and diagnoses including Alzheimer's disease, dementia without behaviors, falls, anxiety and depression. Review of a significant change minimum data set (MDS) assessment dated [DATE] revealed Resident #94 was cognitively impaired. Review of nurses' notes revealed Resident #94 expired in the facility on [DATE]. Review of Resident #94's funds authorization revealed it was signed and witnessed on [DATE]. Review of Resident #94's funds transaction report indicated a final dispersal was not completed until a check was sent…
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 before2022-04-15 · 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 interview, medical record review, and facility policy review, the facility failed to prevent resident to resident sexual abuse. This affected affected four residents (Resident #35, Resident #39, #47, and #95) of four residents reviewed for abuse. The facility census was 88. Findings include: Review of the medical record for Resident #35 revealed an admission date of 06/27/14, with diagnoses including unspecified diastolic congestive heart failure, osteoporosis, history of falling, glaucoma, type 2 diabetes, Parkinson's disease, obsessive-compulsive disorder, unspecified dementia, anxiety disorder, major depressive disorder, and delusional disorder. Review of the progress notes dated 11/18/21 at 1:15 P.M. revealed a state tested nursing assistant (STNA) observed Resident #35 with his hand on the breast of a female resident. The residents were immediately separated, and Resident #35 was wheeled back to his room and placed in bed at his request. Review of the progress notes dated 01/16/22 at 11:55 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 · D2022-04-15 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, medical record review, and facility policy review, the facility failed to report allegations of abuse in a timely manner as required. This affected one resident (Resident #39) of three residents reviewed for reporting allegations of abuse. The facility census was 88. Findings include: Review of the facility Self-Reported Incident (SRI) #216841 dated 01/19/22 revealed the incident was reported on 01/19/22 but occurred on 01/16/22 at 11:55 A.M. Review of the progress notes for Resident #35 revealed a behavior progress note dated 01/16/22 at 11:55 A.M. stating Resident #35 was observed with hands inside a disoriented female resident's shirt, on her breasts (Resident #39). The residents were separated, and Resident #35 was talked to about his behavior. After being separated, Resident #35 again approached the same resident (Resident #39) and started rubbing her legs. The female resident (Resident #39) was heard saying please don't do that and the residents were again separated. Staff would continue to monitor closely. The progress notes lacked documentation of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-04-15 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were completed following the death of a resident. This affected one resident (Resident #1) of two reviewed MDS assessments. Findings include: Review of closed medical record for Resident #1 revealed an admission date of 09/26/21 and a date of death of [DATE] with diagnoses of unspecified protein-calorie malnutrition, delirium due to physiological condition, anorexia, anemia, hypertension, dementia without behavioral disturbance. No MDS was found to be completed following the death of the Resident #1 on 12/16/21. Interview on 04/14/22 at 12:20 P.M. with Clinical Manager #585 confirmed no MDS was completed following death at the facility for Resident #1. Review of November 2019 revised facility policy titled, MDS Assessment Coordinator, revealed a Registered Nurse (RN) will conduct and coordinate the completion of the MDS.
- Potential for harm · D2022-04-15 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure a resident with a level two mental illness was screened by the appropriate state agency (The Ohio Department of Mental Health) for services and placement in the nursing facility. This affected one resident (Resident #90) of two residents reviewed for Pre-admission Screen and Resident Review (PASRR) status Findings Include: Review of the medical record revealed Resident #90 was initially admitted from the hospital on [DATE] and readmitted on [DATE] with diagnoses including dementia with behavior, unspecified psychosis, and major depressive disorder. Review of the hospital exemption PASRR screening form dated 11/07/17 for Resident #90 did not reveal a level of mental illness and/or developmental disability. Interview on 04/12/22 at 10:00 A.M. with Social Worker (SW) #567 revealed PASRR for Resident #90 was unable to be located. Interview on 04/13/22 at 12:56 P.M. with SW #577 revealed she was unable to locate a completed PASRR for Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-04-15 · 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, interview, record review, and review of facility policy, the facility failed to provide appropriate care and services and ensure physician orders were followed for one Resident #444 to prevent pressure ulcers from developing on the buttocks, thighs, and sacral area. This affected one resident (Resident #444) out of three residents reviewed for wounds. Findings include: Review of Resident #444's medical record revealed an admission date of 03/23/22 and diagnoses included osteomyelitis, hemangioma of intracranial structures, and paraplegia. Resident #444 was discharged from the facility on 04/11/22. Review of Resident #444's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #444 was cognitively intact and required extensive assistance of two staff members for bed mobility and transfers. Resident #444 required total dependence of one person for toilet use. Resident #444 did not have a pressure ulcer, had an indwelling catheter and was frequently incontinent of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-04-15 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Resident #78 wore a hand splint per physician order. This affected one resident (#78) out of two residents reviewed for positioning and range of motion (ROM). Findings include: Review of Resident #78's medical record revealed an admission date of 09/25/17 with diagnosis including dementia with behaviors disturbance and contracture of the left hand. Review of the quarterly admission Minimum Data Set (MDS) dated [DATE] revealed the resident was severely cognitively impaired. Review of the physicians orders from April 2022 revealed an order on 03/07/22 for a left hand splint to remain on at all times except during hygiene care. Observation on 04/12/22 at 8:45 A.M. revealed Resident #78 was in the common room not wearing a hand splint. Observation on 04/13/22 at 4:46 P.M. revealed Resident #78 was in the common room not wearing a hand splint. Interview on 04/13/22 at 4:52 P.M. with Licensed Practical Nurse (LPN) #528 revealed the LPN…
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 · D2022-04-15 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review and review of facility policy, the facility failed to ensure oxygen for one resident (Resident #93) was administered per physician orders. This affected one resident (Resident #93) out of three residents reviewed for oxygen administration. Findings include: Review of Resident #93's medical record revealed an admission date of 03/18/22 and diagnoses included chronic atrial fibrillation, biventricular heart failure, and chronic venous hypertension with ulcer and inflammation of the right lower extremity. Review of Resident 93's admission Minimum Data Set (MDS) 3.0 assessment dated , 03/26/22 revealed Resident #93 required the extensive assistance of one staff member for bed mobility, was total dependence of two staff members for transfers, and total dependence of one staff member for toilet use. Resident #93 used oxygen. Review of Resident #93's care plan dated, 03/21/22 included Resident #93 had altered respiratory status, difficulty breathing related to risk for COVID-19. Resident #93 would maintain normal breathing pattern as 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 · Dcited before2022-04-15 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, medical record review, and facility policy review, the facility failed to ensure accurate documentation was contained in the medical record. This affected one (Resident #67) of four residents reviewed for documentation of medication administration. The facility census was 88. Findings include: Review of the medical record for Resident #67 revealed an admission date of 02/16/21 and a readmission date of 11/30/21. Diagnoses included wedge compression fracture of lumbar vertebrae, cyst of kidney, dysphagia, hypertension, pneumonia, and elevation of levels of liver enzymes (transaminase). Observation of medication administration on 04/12/22 at 8:15 A.M. by Licensed Practical Nurse (LPN) #580 for Resident #67 revealed the resident was administered Miralax (laxative) 17 grams (gm) powder mixed in four ounces of water, Preservation Areds (eye vitamin), Senna-S (laxative) 8.6-50 milligrams (mg), Vitamin D3 5000 units, and Atenolol (medication for high blood pressure or chest pain) 25 mg. There were 4 pills verified with LPN #580 prior to administration. 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 · Fcited before2019-04-25 · 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, record review and interview, the facility failed to ensure the nursing unit refrigerators were kept in sanitary conditions and proper storage of residents' food. This had the potential to affect all residents except Residents #86 and #242 who received nothing by mouth. Findings include: Tour of the nursing units on 04/22/19 between 9:47 A.M. and 10:01 A.M. with Dietary Manager (DM) #250 for observation of the nursing unit refrigerators. Observation of the refrigerator in the Regency dining room located on the east side for nursing units 100-400 revealed the refrigerator was kept locked and inside had various food items that were either wrapped, in containers from the kitchen with lids that were unlabeled and undated. The refrigerator located on the west side for nursing units 500 and 800 had various dried reddish spills on the shelves inside the refrigerator. The refrigerator located on the dementia unit (Arthur's Place) had various residents' foods that were unlabeled and undated in containers from the kitchen with lids and other containers. There was also…
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 · E2019-04-25 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview, the facility failed to ensure the interventions for a fall care plan were implemented, failed to ensure a resident with an order for hospice had a hospice care plan, and failed to ensure a resident's care plan was individualized regarding behaviors. This affected three residents (Resident #43, Resident #48, and Resident #39) of 30 residents reviewed for care plans. Findings Include: 1. Review of the medical record revealed Resident #43 was admitted to the facility on [DATE]. His admitting diagnoses included dementia, syncope, macular degeneration and hypertension. Review of the quarterly Minimum Data Set Assessment (MDS) dated [DATE] revealed the resident had severe cognitive impairment. Functionally, the resident required extensive assistance for bed mobility. He was totally dependent on staff for transfers, dressing, toilet use and personal hygiene. Review of the plan of care dated 09/20/17, revealed Resident #43 was at risk for falls related to confusion,…
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 before2019-04-25 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure staff washed their hands between the assisting feeding of six residents (Residents #29, #36, #65, #75, #88 and #124) in the main dining room on the locked dementia unit and failed to ensure a catheter drainage bag for one resident (Resident #88) was kept off of the floor and out of danger of being stepped on. This had the potential to affect 13 additional residents (Residents #14, #23, #31, #33, # 41, #44, #63, #66, #87, #90, #91, #117, and 118) who ate in the main dining room on the dementia unit and eight additional residents (Residents #9, #14, #23, #66, #93, #94, #193, and #194) who had catheters in place. The facility census was 138. Findings include: 1. Observation on 04/22/19 from 12:45 P.M. to 1:40 P.M. of the main dining room on the secured dementia unit revealed State Tested Nursing Assistant (STNA) #190 was feeding Resident #29 and turned to open food items and began feeding Resident #75. The STNA alternated between…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-04-25 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview, the facility failed to ensure a physician's order for the use of oxygen. This affected one resident (Resident #55) of one resident reviewed for oxygen. Findings include: Review of the medical record revealed Resident #55 was admitted to the facility on [DATE]. His admitting diagnoses included Parkinson's disease, pneumonitis due to inhalation of food, acute respiratory failure, Methicillin resistant staphylococcus, repeated falls, pain in right shoulder, major depressive disorder, and carcinoma in situ of the prostate. Review of this resident's annual Minimum Data Set Assessment (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact. Functionally, he required extensive assistance for most activities of daily living including bed mobility, transfers, toileting, dressing, and personal hygiene. He was independent for eating. Observations of this resident on 04/22/19 and 04/24/19 revealed the resident was receiving oxygen via nasal cannula.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-04-25 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure physician ordered medications were readily available in a timely manner for Resident #38. This affected one of five residents reviewed for unnecessary medications. The facility census was 138. Findings Include: Review of the medical record for Resident #38 an admission date of 12/19/18 with diagnoses including fractured femur, dysphagia and high blood pressure. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #38 had moderate cognitive impairment and required extensive assistance for her activities of daily living. Review of the nursing progress notes for Resident #38 noted Resident #38 was admitted at approximately 9:00 P.M. on 12/19/18 and all admitting medication and related orders were verified with Resident #38's physician on 12/19/18 at 10:34 P.M. Review of the electronic medication administration record (EMAR) for 12/19/18 revealed no medications were given to Resident #38 on the evening…
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 before2019-04-25 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure documentation of Resident #55's oxygen saturation was accurate. This affected one resident (Resident #55) of one resident reviewed for oxygen. Findings Include: Review of the medical record revealed Resident #55 was admitted to the facility on [DATE]. His admitting diagnoses included Parkinson's disease, pneumonitis due to inhalation of food, acute respiratory failure, Methicillin resistant staphylococcus, repeated falls, pain in right shoulder, major depressive disorder, and carcinoma in situ of the prostate. Review of this resident's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact. Functionally, he required extensive assistance for most activities of daily living including bed mobility, transfers, toileting, dressing, and personal hygiene. He was independent for eating. Review of the oxygen saturation documentation from December 2018 to present revealed in December 2018 on five occasions…
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 · Ccited before2019-04-25 · tag F0814 — failed to dispose of garbage properly — widespreadDispose of garbage and refuse properly.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, record review and interview, the facility failed to ensure the outside dumpsters were maintained in a sanitary manner. This had the potential to affect all residents. The facility census was 138. Findings include: Observation on 04/22/19 at 9:45 A.M. of the outside dumpsters with Dietary Manager (DM) #250 revealed two large, blue dumpsters. The dumpster on the left was filled to the top with trash with the lid unable to be closed. The dumpster on the right had a white, plastic bag on the top of the closed lid. There was a moderate amount of debris in the field surrounding and between both dumpsters. Interview at this time with DM #250 verified the findings and stated she will have one of the porters clean it up. Review of policy undated and titled Proper Garbage and Refuge Disposal, revealed the area around the dumpster is to be kept free of overflow by the maintenance department. When the garbage is taken to the dumpster the cover is closed and the area is picked up by the person taking the garbage out to prevent infestation.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| ORLEAN, DAVID | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; LIMITED PARTNERSHIP INTEREST; ADP OF THE SNF | 59% | since 02/01/1993 |
| ORLEAN, DEBRA SUE | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; LIMITED PARTNERSHIP INTEREST; ADP OF THE SNF | 20% | since 02/01/1993 |
| ORLEAN, SUSAN | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; LIMITED PARTNERSHIP INTEREST; ADP OF THE SNF | 20% | since 02/01/1993 |
| SHULA, MATTHEW | Individual | CORPORATE DIRECTOR | — | since 10/19/2008 |
| SOVEREIGN ROCKY RIVER, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 08/31/2004 |
| CONNOLLY, EMILY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/11/2022 |
| KUBINSKI, JAMES | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 02/16/2022 |
| NORMANDY II, INC. | Organization | GENERAL PARTNERSHIP INTEREST; LIMITED PARTNERSHIP INTEREST | — | since 02/01/1993 |
| PATEL, KISHOR | Individual | ADP OF THE SNF | — | since 10/01/2022 |
CMS files one row per role, so the 19 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $80K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OH
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Ohio Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 365926. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-07-11, 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.