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Blossom Nursing And Rehab Center

109 Blossom Lane, Salem, OH 44460 · For profit - Corporation · 100 certified beds · (330) 337-3033 Medicare & Medicaid certified

Call the home — (330) 337-3033 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Resident-funds citations (F0568, F0569)1 actual-harm citation
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has citations for mishandling residents’ money or property (F0568, F0569)
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • about 20% of its spending goes to commonly-owned related companies

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

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

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1830 S Lincoln Ave · (330) 332-0709 · Call to confirm hours
Pharmacy
229 N Ellsworth Ave · (330) 337-8727 · Call to confirm hours
Grocery
1735 S Lincoln Ave · (330) 332-8508 · Call to confirm hours
Park
Wh Mullins Memorial Park · Typically dawn to dusk
Place of worship
1779 Depot Rd · (234) 564-1374

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 3 of 5
Long-stay residentspeople who live here 4 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 improved from 3 to 4 stars. From monthly CMS archive snapshots.

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

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased14.0%5.3%15.4%typical
Long-stay residents who lose too much weight7.3%6.2%5.4%worse
Long-stay residents with a catheter left in their bladder1.3%0.2%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection1.0%0.4%2.0%worse than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms0.0%30.1%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury6.1%3.2%3.3%worse
Long-stay residents whose ability to walk worsened14.8%6.1%16.1%typical
Long-stay residents on antianxiety or hypnotic medication18.6%25.5%18.9%typical
Long-stay residents given the seasonal flu vaccine100.0%94.5%95.3%typical
Long-stay residents with pressure ulcers7.2%3.4%4.7%worse
Long-stay residents with worsening bladder/bowel control9.2%21.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table3.9%8.8%17.1%better
Short-stay residents who newly got an antipsychotic medication2.7%1.2%1.4%worse
Short-stay residents given the seasonal flu vaccine85.4%75.6%79.4%typical
Short-stay residents rehospitalized after admission17.5%24.9%22.6%better
Short-stay residents with an outpatient ER visit13.2%12.9%12.0%typical
Long-stay hospitalizations per 1,000 resident days1.471.731.67better
Long-stay outpatient ER visits per 1,000 resident days1.111.801.80better

* 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.

67.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 124 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

67.4%U.S. median 51.5%
Got home and stayed home
11.5%U.S. median 10.7%
Went back to hospital
25.0%U.S. median 56.6%
Met the expected recovery
0.52U.S. median 0.31
Therapy hours / resident / day
0.17hours / resident / day
Physical therapy
0.29hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 25.0% 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 48 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 0.52 therapist hours per resident per day in 2026Q1 — more than 82% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF67.4%CMS range 57.9–74.251.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.5%CMS range 7.5–14.810.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge25.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge25.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge29.2%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting89.8%100.0%Oct 2024–Sep 2025CMS 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened4.2%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.8%CMS range 3.5–10.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.281.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.59
RN hours/ resident / day
0.86
LPN hours/ resident / day
1.92
Aide hours/ resident / day
3.37
Total nurse hours/ resident / day
0.42
RN hoursweekends
37.7%
Total nursing turnover
28.6%
RN turnover

How full it usually is: this home is certified for 100 beds and averages 87.9 residents a day — about 88% occupied, or roughly 12 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 3.37 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.59 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.92 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 2.94 hrs/resident/day on weekends vs 3.55 on weekdays — 17% thinner on weekends. RN hours go from 0.66 to 0.42 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 38% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

3
deficiencies at the latest standard inspection (2025-12-11)
9
at the previous standard inspection (2022-12-09)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

22 citations, most serious first. The 11 most serious are shown; the remaining 11 are one tap away and print in full.

  • Actual harm · Gcited before2022-12-09 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to implement an individualized and effective pressure ulcer prevention program to prevent the in house development and/or worsening of pressure ulcers to Resident #11's bilateral heels. Actual harm occurred on 09/22/22 when Resident #11, who was severely cognitively impaired, required extensive assistance from two staff for bed mobility and was at risk for developing pressure ulcers was identified to have a blister to the left heel without evidence of adequate care/interventions to promote healing. On 09/30/22 Resident #11 was assessed to have a blister measuring 5.0 centimeters (cm) in length by 6.0 cm width with no depth to her right heel with no evidence adequate care/interventions to promote heating. On 10/13/22 the wound physician noted the left heel pressure ulcer had deteriorated and was a deep tissue injury (DTI), a persistent non-blanchable deep red, purple, or maroon areas of intact skin, non-intact skin or blood-filled blisters…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-08 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, review of the facility investigation, interview with staff and review of facility policy, the facility failed to ensure Resident #1 was free from significant medication errors. This affected one resident (Resident #1) of three residents reviewed for medication administration. The facility census was 86. Findings include:Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included hydronephrosis, urinary tract infection, acute kidney disease, atrial fibrillation, congestive heart failure, acute metabolic acidosis, diabetes, cerebral ischemia, obstructive sleep apnea, anxiety disorder, and major depressive disorder. Resident #1 was discharged to the hospital on [DATE]. Review of the admission Minimum Data Set assessment dated [DATE] revealed Resident #1 had intact cognition. Review of the progress note dated 03/31/26 at 10:05 P.M. which was recorded as a Late Entry on 04/01/26 at 6:26 A.M., revealed Resident #1 was given…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-11 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on medical record review and staff interview the facility failed to ensure resident pre-admission screening and resident review (PASARR) was resubmitted after a new psychiatric diagnosis. This affected one (Resident #9) of one residents reviewed for PASARR. The facility census was 91. Review of Resident #9's medical record revealed an admission date of 02/08/23 with admission diagnosis that included mood disorder. Further review of the medical record revealed that on 04/05/23 a new diagnosis of bipolar disorder was added and on 12/13/23 a new diagnosis of schizoaffective disorder was also added. Review of Resident #9's PASARR revealed it was completed on 02/13/23 and identified the diagnosis of mood disorder. No further evidence of any resubmission of PASARR was found after the new psychiatric diagnoses on 04/05/23 and 12/13/23. Interview with Social Services (SS) #117 on 12/09/25 at 11:55 A.M. verified the PASARR was not resubmitted for Resident #9 after new psychiatric diagnoses added on 04/05/23 and 12/13/23.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-11 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, medical record review and staff interview the facility failed to ensure indwelling urinary catheter care was documented and assessed appropriately. This affected one (Resident #78) of two residents reviewed for indwelling urinary catheter use. The facility identified eight residents (#2, #3, #6, #7, #56, #67, #78 and #100) currently utilizing an indwelling urinary catheter. The facility census was 91.Observation of Resident #78 on 12/08/25 at 10:08 A.M. identified the current use of an indwelling urinary catheter. Review of Resident #78's medical record revealed an admission date of 11/30/25 with admission diagnoses that included urinary retention, osteonecrosis of the right knee and convulsions. Further review of the medical record revealed upon admission a physician's order for the use of an indwelling urinary catheter and catheter care to be provided every shift. Further review of the medical record found no evidence of any assessment which identified the current use and indication for the indwelling urinary catheter. Review of the treatment administration…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-11 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, facility policy review, and review of guidelines from the Centers for Disease Control and Prevention, the facility failed to ensure staff used appropriate infection control practices using required proper hand hygiene for Resident # 6 with use of gloves during incontinence care for Residents #6. This affected one ( Resident #6) and had the potential to affect all 91 residents residing in the facility.Findings include:Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including but not limited to Alzheimer's disease, unspecified, Diverticulosis of intestine, part unspecified, without perforation or abscess without bleeding, Urinary tract infection, site not specified, Retention of urine, unspecified, Generalized anxiety disorder, Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease, Diabetes mellitus due to underlying condition with diabetic…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to ensure care planned fall prevention interventions were in place to prevent falls. This affected one resident (Resident #8) of three residents reviewed for accidents. The facility census was 92. Findings include: Review of Resident #8's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including spondylosis without myelopathy or radiculopathy, dementia, difficulty walking, history of falls, and cerebral infarction. The resident was discharged on 03/16/24. Review of the plan of care, dated 09/19/23, revealed Resident #8 was at risk for falls with interventions including toileting offer every two hours, staff to check footwear when delivering tray prior to meal, apply proper non-skid footwear if found to have none on prior meal, educate on the use of the call light for assistance, and call light to be kept within reach. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/10/24,…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-06 · tag F0568 — isolated
    Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of resident accounts and interview, the facility failed to ensure accurate accounting of resident funds were maintained. This affected one (Resident #93) of three residents reviewed for resident funds. The facility identified a total of 58 residents, both current and discharged , who had funds maintained by the facility. Findings include: Review of Resident #93's quarterly fund statement for the first quarter of 2023 revealed social security funds were credited to the account on 01/01/23 and twice on 03/01/23. No pension funds were documented as deposited in January 2023. Pension funds were deposited in February and March of 2023. A liability payment of $1102.00 was withdrawn from Resident #93's account on 01/01/23. No liability was withdrawn in February or March 2023. During review of resident personal funds accounts with Business Office Manager (BOM) #100 on 09/06/23 between 1:45 P.M. and 2:02 P.M., BOM #100 revealed Resident #93 had a patient liability amount of $1169.00 starting 01/01/23. BOM #100 verified no pension deposit was posted in January 2023 and was…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-06 · tag F0569 — isolated
    Notify 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 resident funds account review, record review, and interview, the facility failed to ensure conveyance of resident funds within 30 days of discharge or death. This affected three (Residents #93, #94, and #95) of three residents reviewed for personal funds. The census was 92. Findings include: 1. Review of Resident #94's closed medical record revealed an admission date of [DATE] with diagnoses including cerebral infarction, depression, epilepsy and type two diabetes mellitus. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #94 was usually able to understand others. Resident #94 was assessed as moderately cognitively impaired. Resident #94 discharged to another facility on [DATE]. Review of Resident #94's personal funds consent dated [DATE] revealed Resident #94 authorized the facility to manage his personal money while he was a resident. Upon discharge, the account would be closed and the funds would be returned to Resident #94. The facility was to furnish a final statement no…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-12-09 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed ensure oxygen tubing/nasal cannulas and aerosol equipment (tubing/mouthpieces) for respiratory treatments were changed and dated weekly and properly stored to prevent infection/contamination when not in use for Residents #8, #36, #37 and #49. This affected four of 13 residents reviewed for oxygen therapy/breathing treatments. Findings included: 1. Review of the medical record revealed Resident #36 was admitted to the facility on [DATE]. Diagnoses included chronic pulmonary (lung) disease, chronic respiratory failure, hypertension, atrial fibrillation, diabetes, anxiety, obstructive sleep apnea, atherosclerotic heart disease, affective mood disorder, and insomnia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 was alert,oriented with intact cognition, required extensive assistance of two staff members for bed mobility, transfers, toilet use and one staff member for dressing and personal hygiene.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-09 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility filed to ensure Resident #36 received showers per her preference. This affected one resident (#36) of three reviewed for choices. Findings include: Review of the medical record revealed Resident #36 was admitted to the facility on [DATE]. Diagnoses included chronic pulmonary disease, chronic respiratory failure, hypertension, atrial fibrillation, diabetes, anxiety, obstructive sleep apnea, atherosclerotic heart disease, muscle weakness, hypothyroidism, affective mood disorder, and insomnia. Review of the admission Minimum Data Set assessment dated [DATE] revealed Resident #36 had intact cognition, required extensive assistance of two staff members for bed mobility, transfers, toilet use and one staff member for dressing and personals hygiene. Review of the current facility shower schedule revealed Resident #36 was to have a shower on afternoon shift on Tuesdays, Thursdays and Saturdays. Review of progress notes from 09/23/22 to 12/04/22 revealed no evidence…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-09 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    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 resident's confidential information was not left visible on unattended computer screens. This affected three residents (Resident #51, #67 #74) of six observed for medication administration. Findings included: 1. Review of the medical record revealed Resident #51 was admitted to the facility on [DATE]. Diagnoses included diabetes, major depressive disorder, COVID-19, dysphagia, port-traumatic stress disorder, anxiety disorder, chronic obstructive pulmonary disease, atrial fibrillation, chronic kidney disease, gout, and osteoarthritis. Observation on 12/05/22 at 11:07 A.M. revealed Licensed Practical Nurse (LPN) #815 assembled her equipment and went into the room of Resident #51 to perform blood glucose testing. LPN #815 left Resident #51's medical information on the computer screen. LPN #815 verified at 11:19 A.M. she had not closed out the resident information on her computer screen when she went into the resident's room. Review of…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 11 citations
  • Potential for harm · D2022-12-09 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews the facility failed to ensure appropriate nail care was provided to Resident #32, who was dependent on staff for her personal care. This affected one of three residents reviewed for activities of daily living (ADLs). Findings included: Review of the medical record revealed Resident #32 was admitted to the facility on [DATE]. Diagnoses included dementia, chronic kidney disease, weakness, macular degeneration, diabetes, major depressive disorder, anemia, congestive heart failure, hypothyroidism, osteoarthritis, and COVID-19. Review of the plan of care dated 11/20/18 revealed Resident #32 was limited in her ability to perform all ADLs due to chronic kidney disease, acute kidney failure, and diabetes with neuropathy. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #32 had moderately impaired cognition and required extensive assistance of one staff for personal hygiene. Review of the progress notes dated 05/22/22 through 11/30/22…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-09 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure Resident #23 received an appropriate substitution for his physician ordered nutritional supplement and the facility failed to timely assess Resdient #75 for the use of a Broda chair. This affected one of five residents reviewed for nutrition and one of one resident reviewed for a possible restraint. The facility census was 85. Finding included: 1. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE]. Diagnoses included squamous cell carcinoma of skin, acute respiratory failure, severe protein calorie malnutrition, diabetes, atrial fibrillation, chronic lymphatic leukemia, major depressive disorder, chronic obstructive pulmonary disease, hypertension, atherosclerotic heart disease, nutritional deficiency, and anxiety disorder. Review of the significant change Minimum Data Set assessment dated [DATE] revealed Resident #23 had moderately impaired cognition and had a prognosis of less than six months…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-09 · tag F0685 — isolated
    Assist a resident in gaining access to vision and hearing services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure glasses were provided for Resident #17 in a timely manner following a optometry appointment. This affected one of one resident reviewed for vision. The facility census was 85. Findings include: Review of Resident #17's medical record revealed an admission date of 07/26/22 with diagnoses that included congestive heart failure, pressure ulcer to the sacrum and diabetes mellitus. Review of the 360 Optometry consult revealed Resident #17 was evaluated in the facility on 07/24/22. At that time the optometrist ordered new glasses pending insurance/payer approval. The Minimum Data Set (MDS) 3.0 quarterly assessment with a reference date of 11/03/22 revealed Resident #17 was alert and oriented with intact cognition. This assessment indicated Resident #17 had impaired vision and but did not use any corrective lenses. Further review of the medical record found no evidence of any approval or additional notes related to approval or lack thereof for Resident #17's glasses. Interview with Resident #17 on 12/04/22 at 10:54 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-12-09 · tag F0805 — failed to prepare food in a form residents can eat — isolated
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    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 Resident #186's meal consistency was provided per the physician order. This affected one (Resident #186) of seven residents reviewed for food and nutrition. Findings include: Review of Resident #186's medical record revealed she was admitted on [DATE] with diagnoses including cardiomegaly, diabetes and hemiplegia. Review of Resident #186's physician orders revealed an order dated 11/29/22 for a pureed diet with sugar substitute and thin liquids. Observation on 12/05/22 at 12:10 P.M. revealed Resident #186 was sitting in the dining room on the 100/200 units and she was served a pureed plate of stuffed cabbage with mashed potatoes. On the left side of the plate was a square piece of white cake with icing which was not pureed as indicated in the physician orders. Interview on 12/05/22 at 12:10 P.M. with Dietary Supervisor #885 confirmed Resident #186 was served white cake with icing which had a regular consistency, which was an error…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-12-09 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to perform hand washing prior to administering insulin to Resident #51 to prevent the potential spread of infection. This affected one resident (Resident #51) of two observed for injections. Findings include: Review of the medical record revealed Resident #51 was admitted to the facility on [DATE]. Diagnoses included diabetes, post-traumatic stress disorder, anxiety disorder, and chronic obstructive pulmonary disease. Review of the December 2022 physician orders revealed Resident #51 had a order for Humalog, an injectable insulin medication for diabetes, 10 units three times daily. Observation of glucometer testing on 12/05/22 at 11:07 A.M. revealed Licensed Practical Nurse (LPN) #815 assembled her equipment and went into Resident #51's room. LPN #815 completed the blood sugar test with the glucometer and placed it on Resident #51's bedside table. LPN #815 went back to the medication cart in the hallway cleaned the glucometer with a Sani-wipe,…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2020-01-09 · tag F0803 — failed to meet residents' dietary needs — widespread
    Ensure 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

    Based on observation, record review and staff interview the facility failed to ensure menu pureed and regular portion sizes were followed during the lunch meal on 01/07/20. This had the potential to affect 94 of 94 residents who received meal trays from the facility, with the exception of Resident #141 who did not receive nutrition from the kitchen. The facility census was 95. Findings include: Review of the lunch menu/spreadsheet for the 01/07/20 lunch meal revealed the meal included mustard glazed beef, mashed potatoes, carrots or green beans, wheat bread and assorted desserts. Observation of the lunch tray line on 01/07/20 at 11:20 A.M. with [NAME] #106 and Dietary Manager #102 revealed the serving of wheat bread was not served with the lunch meal. Review of the menu spreadsheet for Week 3 Day 3 revealed the meal included one slice of wheat bread. Observation of the pureed diet revealed the pureed mustard glazed beef was served with a #8 (four ounce scoop). Review of the menu spreadsheet revealed the pureed beef was to be served with a #6 (5 1/3 ounce scoop), more than what was…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2020-01-09 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure 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 staff interview the facility failed to ensure food was stored and prepared under sanitary conditions. This had the potential to affect 94 of 94 residents who received meal trays from the facility, with the exception of Resident #141 who did not receive nutrition from the kitchen. The facility census was 95. Findings include: Initial tour of the kitchen on 01/06/20 at 9:45 A.M. revealed the following: The walk in refrigerator contained: - leftover peas which not dated - leftover beef a roni dated 12/30/19 - leftover gluten free pancake mix dated 12/18/19 In the walk in freezer: - chocolate ice cream was observed with the lid off - French toast with the bag opened and not sealed exposing the french toast the freezer air - beef tacos open to air - eggplant cutlets open to air - ground beef patties open to air The reach in refrigerator contained the following: There were three individual servings of cottage cheese dished out and not covered. There were six yogurt and eight jello in individual cups uncovered on a tray dated 01/04/20. There 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2020-01-09 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure a timely pressure ulcer re-assessment was completed for Resident #51, following the resident's readmission to the facility and failed to implement physician orders for pressure ulcer prevention and treatment for Resident #76. This affected two residents (#51 and #76) of four residents reviewed for pressure ulcers. The facility identified eight residents with pressure ulcers. Findings include: 1. Review of Resident #51's medical record revealed an admission date of 02/14/18 with diagnoses including end stage renal disease, acquired absence of right leg above knee amputation, periprosthetic fracture around internal prosthetic left hip joint, respiratory failure, anemia, weakness, hyperlipidemia, dependence on renal dialysis, hypothyroidism, obstructive sleep apnea, Type 2 diabetes mellitus, chronic systolic (congestive) heart failure, macular degeneration, hypertension, morbid (severe) obesity, major depressive disorder, generalized…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2020-01-09 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and staff interview the facility failed to ensure a contracture splinting device was in place as ordered by the physician for Resident #13. This affected one resident (#13) of two residents reviewed for limited range of motion. The facility identified eight residents with limited joint range of motion. Findings include: Review of Resident #13's medical record revealed an admission date of 06/09/2016 with admission diagnoses that included cerebrovascular accident with hemiplegia and hemiparesis. Review of the medical record revealed on 02/15/2019 Resident #13 had a physician order for the use of a left cock up splint to be worn from 9:00 A.M. to 5:00 P.M. to prevent further loss of range of motion. Review of the medical record found no evidence Resident #13 was receiving any physical or occupational therapy services at this time. Review of Resident #13's plan of care revealed a care plan in place for a limitation of range of motion and an intervention including the use of a left wrist cock up splint to be worn per restorative. Review of 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2020-01-09 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide 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, record review and interview the facility failed to ensure physician's orders were followed for Resident #191 related to an indwelling urinary catheter and failed to ensure the resident had an appropriate indication for use of the indwelling urinary catheter. This affected one resident (#191) of two residents reviewed for indwelling urinary catheter use. The facility identified six residents with use of any indwelling urinary catheter. Findings include: Review of Resident #191's medical record revealed an admission date of 12/20/2019 with diagnoses that included left femur fracture with surgical repair and infection to the surgical area. Further review of the medical record revealed a nurse to nurse communication form from the transferring facility on 12/20/2019 that indicated the use of an indwelling urinary catheter and instructed the facility to remove the catheter in seven days. Review of the physician's orders revealed an order for the indwelling catheter to be removed in one week.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2020-01-09 · tag F0805 — failed to prepare food in a form residents can eat — isolated
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and staff interview the facility failed to pureed food to the correct consistency. This had the potential to affect three residents (#27, #31 and #60) who received a pureed diet. The facility census was 95. Findings include: Observation on 01/07/20 at 3:20 P.M. revealed [NAME] #104 was pureeing the supper meal. Riblet sandwiches were substituted for the ham on the Week three Day three supper menu. [NAME] #104 placed 10 and 2/3 bun halves in the cuisinart. [NAME] #104 added one half cup of water, one fourth cup barbeque sauce, one half teaspoon beef base, and two tablespoons of thickener. [NAME] #104 added 10 ounces of riblet to the mixture and blended. The mixture was placed in a tin. [NAME] #104 did not taste the mixture for consistency. When asked to check the consistency there was fibrous tissue in the puree. DM #102 tasted the puree verifying fibers were not fully broken down. [NAME] #104 returned the puree to the cuisinart and was pureed to a creamy consistency. Interview on 01/07/20 at 3:50 P.M. with DM #102 verified the riblet sandwich puree was not…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to ATRIUM CENTERS — 26 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 53.0+1.0 vs chain
Health inspection 4 of 52.7+1.3 vs chain
Staffing 3 of 53.4-0.4 vs chain
Quality measures 3 of 53.7-0.7 vs chain
The other 25 homes this chain runs (chain average 3.0★, per CMS)
1 of 5Marshall Nursing and Rehabilitation CommunityMarshall, MI 1 of 5Mulder Health Care FacilityWest Salem, WI 1 of 5Riverside Nursing CentreGrand Haven, MI 2 of 5Allendale Nursing and Rehabilitation CommunityAllendale, MI 2 of 5Plainwell Pines Nursing and Rehabilitation CommuniPlainwell, MI 2 of 5Roosevelt Park Nursing and Rehabilitation CommunitMuskegon, MI 2 of 5South Haven Nursing and Rehabilitation CommunitySouth Haven, MI 2 of 5The Timbers of Cass CountyDowagiac, MI 2 of 5Tomah Nursing And RehabTomah, WI 2 of 5Westgate Nursing & Rehabilitation CommunityIronwood, MI 3 of 5Austinburg Nsg And Rehab CtrAustinburg, OH 3 of 5Crittenden County Health & Rehabilitation CenterMarion, KY 3 of 5Frederic Nursing And Rehab CommunityFrederic, WI 3 of 5Lincoln Haven Nursing & Rehabilitation CommunityLincoln, MI 3 of 5Prescott Nursing And Rehab CommunityPrescott, WI 3 of 5Salem Springlake Health & Rehabilitation CenterSalem, KY 3 of 5Woodside Village Care CenterMount Gilead, OH 4 of 5Fairview Nursing and Rehabilitation CommunityCentreville, MI 4 of 5Gladwin Nursing and Rehabilitation CommunityGladwin, MI 4 of 5Grayling Nursing & Rehabilitation CommunityGrayling, MI 4 of 5Heritage Nursing and Rehabilitation CommunityZeeland, MI 4 of 5Lexington Court Care CenterLexington, OH 5 of 5Freeman Nursing & Rehabilitation CommunityKingsford, MI 5 of 5Hillcrest Nursing and Rehabilitation CommunityNorth Muskegon, MI 5 of 5King Nursing & Rehabilitation CommunityHoughton Lake, MI

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

Who owns this facility

Owner / managerTypeRoleShareSince
ORION OPERATING SERVICES LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL100%since 05/16/2007
AMICUS CAPITAL HOLDINGS INCOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 01/01/2021
AMICUS CAPITAL HOLDINGS, INC. EMPLOYEE STOCK OWNERSHIP TRUSTOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 08/18/2021
ATRIUM CENTERS, LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 10/01/2007
PAREDES, MIGUELIndividualINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 08/08/2021
LUMENT REAL ESTATE CAPITAL, LLCOrganization5% OR GREATER MORTGAGE INTERESTsince 05/01/2022
HELLER, DAVIDIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/18/2024
JOHNSON, CINDYIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/18/2024
BAILEY, ESSELIndividualCORPORATE DIRECTORsince 01/01/2021
FINNEY, DONALDIndividualCORPORATE DIRECTORsince 01/01/2021
ALBRIGHT ROSS, SUSANIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF; ADP OF THE SNFsince 01/02/2018
ATRIUM CENTERS MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/18/2024
ANDERSON, CURTIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/01/2025
CHERRY, JILLIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2025
DEMIDOVICH, JAMESIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2025
NORQUIST, JACKIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/17/2018
OSTRANDER, GLORIAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/07/2025
RUSYN, LORIIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/11/2019
AMICUS PROPERTIES LLCOrganizationADP OF THE SNFsince 01/01/2021
BROAD RIVER REHABILITATIONOrganizationADP OF THE SNFsince 09/01/2021
EVERGREEN TWO LLCOrganizationADP OF THE SNFsince 03/24/2026
FORVIS MAZARS LLPOrganizationADP OF THE SNFsince 06/01/2023
LEADERSTAT LTDOrganizationADP OF THE SNFsince 01/01/2025
OCS REAL ESTATE HOLDINGS LLCOrganizationADP OF THE SNFsince 01/01/2021
OMNICARE LLCOrganizationADP OF THE SNFsince 01/01/2025
PLANTE & MORAN PLLCOrganizationADP OF THE SNFsince 01/01/2025

CMS files one row per role, so the 44 rows in the source record cover these 26 parties — each is shown once here with every role it holds. Nothing is omitted.

14 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.

$10.0M
Net patient revenuemost recent cost report
+8.1%
Operating marginrevenue minus expenses
$1.8M
Related-party expense20% of expenses
Who pays — share of resident-days
Medicaid 28%Medicare 9%Other / private 63%

This home reported $1.8M paid to related parties — landlords or management companies under common ownership — equal to about 20% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

Cost & finances

$280per resident / day
operating cost
$8,501per month
≈ monthly operating cost
$304per day
avg. revenue, all payers

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

What families pay in OH

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 366169. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-11, 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.

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