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Ohio Veterans Home

3416 Columbus Ave, Sandusky, OH 44870 · Government - State · 427 certified beds · (419) 625-2454 Medicare & Medicaid certified

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Flagged for abuse2 actual-harm citations1 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (5/5)
Worth asking about
  • CMS has flagged it for abuse
  • it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Nov 2025
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 2 actual-harm citations
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • 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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 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, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
3006 Campbell St · (419) 626-1313 · Call to confirm hours
Pharmacy
3700 Milan Rd · (419) 625-0733 · Call to confirm hours
Grocery
3712 Columbus Ave · (419) 625-6246 · Call to confirm hours
Park
400 Schiller Ave · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

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

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 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 increased10.9%5.3%15.4%worse than state — see note marked double-dagger below the table
Long-stay residents who lose too much weight4.7%6.2%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.2%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.9%0.4%2.0%worse than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms11.2%30.1%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.2%3.2%3.3%better
Long-stay residents whose ability to walk worsened11.8%6.1%16.1%worse than state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication20.3%25.5%18.9%typical
Long-stay residents given the seasonal flu vaccine100.0%94.5%95.3%typical
Long-stay residents with pressure ulcers4.4%3.4%4.7%typical
Long-stay residents with worsening bladder/bowel control26.0%21.4%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table17.8%8.8%17.1%typical
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine97.1%75.6%79.4%better
Short-stay residents rehospitalized after admission10.9%24.9%22.6%better
Short-stay residents with an outpatient ER visit6.8%12.9%12.0%better
Long-stay hospitalizations per 1,000 resident days0.851.731.67better
Long-stay outpatient ER visits per 1,000 resident days0.831.801.80better

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.

44.4%U.S. median 56.6%
Met the expected recovery
0.16U.S. median 0.31
Therapy hours / resident / day
0.08hours / resident / day
Physical therapy
0.05hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 44.4% 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 27 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 0.16 therapist hours per resident per day in 2026Q1 — more than 15% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge44.4%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 discharge22.2%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge33.3%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified97.4%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay2.6%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.6%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFsnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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

0.76
RN hours/ resident / day
1.48
LPN hours/ resident / day
2.63
Aide hours/ resident / day
4.86
Total nurse hours/ resident / day
0.57
RN hoursweekends
36.2%
Total nursing turnover
5.0%
RN turnover

How full it usually is: this home is certified for 427 beds and averages 241.9 residents a day — about 57% occupied, or roughly 185 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.86 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.76 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.63 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 4.40 hrs/resident/day on weekends vs 5.05 on weekdays — 13% thinner on weekends. RN hours go from 0.84 to 0.57 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 36% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

Inspection trend

5
deficiencies at the latest standard inspection (2024-01-11)
5
at the previous standard inspection (2019-10-24)

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

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.

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.

23 citations, most serious first. The 13 most serious are shown; the remaining 10 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2025-11-06 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on review of the medical record, review of a facility Self-Reported Incident (SRI), review of an SRI investigation, review of staff statements, review of the staffing schedule, review of employee time records, review of a police report, review of video surveillance, review of an incident report, staff interviews, resident interview, family interview, and review of facility policy, the facility staff failed to ensure Resident #241 was free from staff to resident verbal and physical abuse. This resulted in Immediate Jeopardy when Resident #241 was thrown from his wheelchair on 09/16/25 at approximately 7:50 P.M. by Licensed Practical Nurse (LPN) #602 placing the resident at risk for potential serious life-threatening harm, injuries, and/or negative health outcomes. Additionally, the facility failed to protect the resident from further abuse and failed to immediately report 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Actual harm · Gcited before2025-06-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of a self-reported incident (SRI) and related investigation documents, review of a hospital record, review of an employee skills checklist, and policy review, the facility failed to complete resident transfers using a mechanical lift with appropriate assistance as care planned and as ordered. Actual Harm occurred on 04/29/25 when Resident #2, who was care planned for two-person assistance with all personal care and had a physician order to always be transferred using two people, was transferred in her room by one staff member using a mechanical lift without assistance. Resident #2 sustained a right femur fracture as a result of the improper transfer. This affected one (#2) of three residents reviewed for accidents. The facility census was 223. Findings Include: Review of Resident #2's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia, peripheral vascular disease, and constipation. Review of the most recent…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2019-10-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, resident interview, review of hospital documentation, review of mechanical lift manufacturer instructions, review of facility mechanical lift policy, and review of facility incident investigation documentation, the facility failed to ensure residents were provided with appropriate supervision during a transfer using a mechanical lift. This resulted in actual harm when Resident #433 sustained a 5.0 centimeter (cm) laceration to the right anterior shin which required suturing. The resident was being transferred with a mechanical lift with only one staff person. This affected one (Resident #433) of three residents reviewed for use of mechanical lift for transferring. Facility census was 390. Findings include; Review of the medical record revealed Resident #433 was admitted to the facility on [DATE]. Diagnoses included myasthenia gravis, type II diabetes mellitus, dementia, major depression, chronic obstructive pulmonary disease, post traumatic stress disorder,…

    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 · E2026-02-05 · tag F0607 — failed to have anti-abuse policies — pattern
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, review of a Self-Reported Incident (SRI), review of a facility investigation, review of staff witness statements, staff interview, and policy review, the facility failed to implement their abuse policy to provide timely interventions and further failed to provide notification to the appropriate medical and support staff for follow-up services. This affected one (#193) of eight residents reviewed for abuse and had the potential to affect all 25 residents on the Unit 3 South. The facility census was 242.Findings include:Review of the medical record for Resident #193 revealed an admission date of 08/29/24. Diagnoses included Alzheimer's disease, dementia, anxiety, hypertension, and dysphagia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of a facility Self-Reported Incident (SRI) dated 01/27/26 revealed staff reported an allegation of staff to resident verbal abuse for Resident #193. Review…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-02-05 · tag F0609 — failed to report abuse allegations — pattern
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, review of a Self-Reported Incident (SRI), review of a facility investigation, review of staff witness statements, staff interview, and policy review, the facility failed to report allegations of staff to resident abuse. This affected six (#244, #93, #243, #129, #193, #6) of eight residents reviewed for abuse and had the potential to affect all 25 residents on the Unit 3 South. The facility census was 242. Findings include:1. Review of the medical record for Resident #193 revealed an admission date of 08/29/24. Diagnoses included Alzheimer's disease, dementia, anxiety, hypertension, and dysphagia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of a facility Self-Reported Incident (SRI) dated 01/27/26 revealed staff reported an allegation of staff to resident verbal abuse for Resident #193. Review of a follow-up investigation report revealed staff witnessed Certified Nursing Assistant (CNA)…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-02-05 · tag F0610 — failed to investigate and act on abuse reports — pattern
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the medical record, review of a Self-Reported Incident (SRI), review of a facility investigation, review of staff witness statements, staff interview, and policy review, the facility failed to thoroughly investigate allegations of staff to resident abuse. This affected six (#244, #93, #243, #129, #193, #6) of eight residents reviewed for abuse and had the potential to affect all 25 residents on the Unit 3 South. The facility census was 242. Findings include:1. Review of the medical record for Resident #193 revealed an admission date of 08/29/24. Diagnoses included Alzheimer's disease, dementia, anxiety, hypertension, and dysphagia.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of a facility Self-Reported Incident (SRI) dated 01/27/26 revealed staff reported an allegation of staff to resident verbal abuse for Resident #193. Review of a follow-up investigation report revealed staff witnessed…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-02-05 · tag F0805 — failed to prepare food in a form residents can eat — pattern
    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 review of the medical record, review of staff statements, staff interview, and policy review, the facility failed to ensure food items were provided per physician orders. This affected one (#93) of three residents reviewed for dietary services and had the potential to affect 14 residents identified by the facility with physician orders for mechanically altered diet textures. The facility census was 242.Findings include:Review of the medical record for Resident #93 revealed an admission date of 09/05/18. Diagnoses included hemiplegia and hemiparesis, dementia, type two diabetes mellitus, and dysphagia.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. The resident was dependent on staff for feeding assistance. Review of the care plan last revised 02/03/26 revealed the resident was at risk for aspiration due to a history of dysphagia. Interventions included to monitor for choking and for signs/symptoms of aspiration and notify…

    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 before2025-06-06 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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 medical record review, review of facility self-reported incidents (SRIs) and investigation documents, staff and resident interview, and review a facility policy, the facility failed to ensure residents were free from verbal and physical abuse. This affected three (#3, #4, and #5) of five residents reviewed for abuse. The facility census was 223. Findings Include: 1. Review of Resident #3's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia, high blood pressure, and depression. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 was severely cognitively impaired and required extensive assistance of two staff persons for completing his activities of daily living (ADLs). Review of an SRI and corresponding investigation documents dated 03/20/25 revealed, on 02/06/25, staff witnesses reported that Certified Nurse Aide (CNA) #102 was deliberately agitating Resident #3 while other staff were providing…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-06 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of facility self-reported incidents (SRI) and related investigation documents, staff and resident interview, review of local new reports, and review of a facility policy, the facility failed to ensure residents were free from misappropriation. This affected one (#1) of five residents reviewed for misappropriation. The facility census was 223. Findings Include: Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included type two diabetes, chronic kidney disease, and gout. Review of the most recent Minimum Data Set (MDS) 3.0 assessment revealed Resident #1 was cognitively intact and required hands on assistance from one staff person for completing his activities of daily living (ADLs). Review of an SRI and corresponding investigation documentation dated 03/31/25 revealed the facility…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · Dcited before2025-06-06 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of a self-reported incident (SRI) and related investigation documents, staff interview, and review of a facility policy, the facility failed to timely report an allegation of abuse to the State Survey Agency in a timely manner. This affected one (#3) of five residents reviewed for abuse. The facility census was 223. Findings Include: Review of Resident #3's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia, high blood pressure, and depression. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 was severely cognitively impaired and required extensive assistance of two staff persons for completing his activities of daily living (ADLs). Review of an SRI and corresponding investigation documents dated 03/20/25 revealed, on 02/06/25, staff witnesses reported Certified Nurse Aide (CNA) #102 was deliberately agitating Resident #3 while other staff were providing 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-28 · tag F0926 — failed to keep the home smoke-free / fire-safe — isolated
    Have policies on smoking.
    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 a police report, review of an incident report, observation, staff interview, and policy review, the facility failed to ensure a resident was adequately assessed for unsupervised smoking and failed to follow the smoking policy. This affected one (#84) of three residents reviewed for smoking safety. The facility identified 38 residents who smoked. The facility census was 223. Findings include: Review of the medical record revealed Resident #84 had an admission date of 12/30/13 and a readmission date of 10/20/23. Diagnoses included paranoid schizophrenia, type two diabetes mellitus, osteoarthritis, anxiety disorder, depression, unspecified psychosis, insomnia, and polyneuropathy. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. The resident required supervision for walking and was independent in wheelchair. Review of the care plan initiated 10/29/23 for Resident #84 revealed the resident had…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-11 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, medical record review and staff interviews, the facility failed to provide the resident with a table of appropriate height to ensure proper eating for one (#139) of 40 sampled residents. The facility census was 186. Finding include: Review of Resident #139's medical record identified admission to the facility occurred on 05/18/23. Diagnoses included Parkinson's disease, dementia, major depression, diabetes and prostate cancer. Review of Resident #139's record identified on 06/01/23 his weight was 161 pounds and on 01/02/24 his weight was 141 pounds, which was a 12.4% loss. Review of Resident #139's plan of care for nutritional concerns identified Resident #139's goal was to ensure adequate intake to prevent weight loss. The plan included interventions for dining which included to ensure the resident was in an upright posture for oral intake and alternating solids and liquids with each bite. Observation of Resident #139 on 01/10/24 at 8:29 A.M., revealed the resident was in the dining room. The dining room was observed with tables of varying heights. 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-11 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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

    Based on review of medical records, resident and staff interviews, the facility failed to ensure residents were included in their care plan meetings. This affected two (#17 and #95) of 40 sampled residents. The facility census was 186. Findings include: 1. Review of Resident #17's medical record identified admission to the facility occurred on 05/24/19. Diagnoses included major depression, diabetes, obesity and anxiety. The records identified Resident #17 with intact cognition. Review of care meeting notes dated 07/27/23 at 11:54 A.M. identified no participation including Resident #17 in his care plan choices. Review of Resident #17's most recent care meeting notes dated 11/09/23 at 12:15 P.M. identified the meeting was held on a phone conference; however, the conference did not include the resident. Interview with Resident #17 on 01/08/24 at 11:51 A.M. revealed he has not attended any care plan meetings, but would like to. Interview with Licensed Social Worker (LSW) #700 on 01/11/24 at 10:04 A.M. revealed residents were not being invited to their care meetings because I share an…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 10 citations
  • Potential for harm · D2024-01-11 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident and staff interviews, the facility failed to ensure residents receive proper treatment and assistive devices to maintain their hearing abilities. This affected one (#79) of one resident identified with hearing issues. The facility census was 186. Findings include: Review of Resident #79's medical records revealed he was admitted on [DATE]. Diagnoses included dementia, psychotic disturbance, mood disturbance, and anxiety. Review of the Minimum Data Set assessment dated [DATE] revealed Resident #79 had moderate cognitive impairment and hearing difficulties. Observation on 01/10/24 at 9:48 A.M. revealed Therapeutic Program Worker (TPW) #460 pushing Resident #79 in a wheelchair. TPW #460 was leaning close towards his ear saying Can you hear me? Resident #79 did not respond. During an interview with Resident #79 on 01/08/24 at 11:46 A.M., Resident #79 was observed at that time with no hearing aides and his television was very loud. Resident #79 stated he has a hard time hearing…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-11 · 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

    Based on observation, resident interview, staff interview, and policy review, the facility failed to ensure safe smoking. This affected two residents (#43 and #171) of two residents reviewed for smoking. The facility census was 186. Findings include: 1. Review of the medical record for Resident #171 revealed an admission date of 11/03/22. Diagnoses included chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and chronic respiratory failure with hypercapnia. Review of the Minimum Data Set (MDS) assessment, dated 11/03/23, revealed Resident #171 had cognition impairment. Review of the MDS assessment revealed Resident #171 utilized oxygen. Review of the care plan, dated 11/16/23, revealed Resident #171 was a smoker and smoked unsupervised. Interventions included following smoking policy and procedure, smoking only in designated areas, storing cigarettes and lighter in medication room, and may keep one or two cigarettes on his person. Further review of the care plan revealed Resident #171 had a history of chronic respiratory failure with hypoxia and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-11 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record review, review of facility policy, and resident and staff interviews, the facility failed to provide adequate pain management which resulted in actual harm to Resident #111 who continued to have uncontrolled pain at a level of 8 out of 10 (with 10 being the highest level). This affected one (#111) of two residents reviewed for pain management. The facility census was 186. Findings include: Review of Resident #111's medical record revealed an admission date of 08/22/23. Diagnoses included chronic pain, chronic obstructive pulmonary disease (COPD), anxiety, depression, and mental and behavioral disorders. Review of Resident #111's quarterly pain assessment, dated 11/16/23, revealed pain over the last five days making it hard to sleep at night, which is frequently limiting his day to day activities. Resident has indicated his pain was moderate and rated as an eight out of 10. The care planning interventions included for the physician to check mark which interventions to utilize…

    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 · F2019-10-24 · 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, staff interview and review of a facility policy, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. This had the potential to affect all residents who resided in the facility except Resident #150 who was identified by the facility to not receive meals from the kitchen. The facility census was 390. Findings include: Observation of food storage on 10/23/19 at 8:56 A.M., revealed a plastic scoop was stored inside of a cardboard box of a powdered thickening agent (a substance which can increase the viscosity of a liquid). Interview on 10/23/19 at 9:21 A.M., [NAME] #165 verified a plastic scoop was stored inside the cardboard box of a powdered thickening agent. Observation on 10/23/19 at 10:07 A.M., revealed a plastic scoop was stored inside of a plastic bin of brown sugar. Interview on 10/23/19 at 10:08 A.M., Food Services Supervisor #550 verified a plastic scoop was stored inside the plastic bin of brown sugar. Review of a facility policy titled, Dry Storage, most recent revision 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2019-10-24 · tag F0803 — failed to meet residents' dietary needs — pattern
    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 and staff interview, the facility failed to provide staff recipes for pureed diets. This directly affected 14 residents (#3, 21, 89, 114, 164, 200, 232, 250, 300, 364, 377, 381, 383 and 384) who the food was prepared for. The facility identified 19 residents who received a pureed diet. The facility census was 390. Findings include: Observation on 10/23/19 at 8:29 A.M., revealed [NAME] #165 placed eight slices of bread in a food processor with roast beef and gravy. After pureeing the mixture, [NAME] #165 divided the mixture into seven separate containers, covered the containers with plastic wrap and marked each container with a specific unit (unit A, D1 and D2, 2 North, B, C, D and 1 North) to be served to the residents on each unit who were ordered a pureed diet. Interview on 10/23/19 at 9:21 A.M., [NAME] #165 revealed she was not sure how may slices of bread she was supposed to use per serving for each pureed open face roast beef sandwich. [NAME] #165 further revealed she did not have a recipe to follow so she put in what she felt was adequate. [NAME] #16…

    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 before2019-10-24 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, resident interview, and staff interview, the facility failed to ensure residents' dignity was respected during the dining experience. This affected one (Resident #26) of two residents reviewed for dignity. The facility census was 390. Finding Include: Review of Resident #26's medical record revealed an admission date of 02/03/10. Diagnoses included dementia with behavioral disturbance, major depressive disorder, Alzheimer's disease, osteoarthritis, peripheral vascular disease, hypertension, diverticulitis, anemia, heart failure and chronic kidney disease. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #26 was moderately cognitively impaired. Resident #26 required supervision for bed mobility, transfer, walking and eating. Resident #26 required extensive assistance with with dressing, toilet use, and personal hygiene. Resident #26 displayed verbal behavioral symptoms directed toward others, behavioral symptoms not directed toward others and…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-10-24 · 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 medical record review, observation and staff interview, the facility failed to ensure residents were properly positioning with positioning devices while in wheelchairs. This affected two (Residents #239 and #354) of three residents reviewed for positioning. The facility census was 390. Findings Include: 1. Review of Resident #239's medical record revealed an admission date of 07/08/19. Diagnoses included mood disorder, anxiety disorder, depressive disorder, dementia, history of falling, and peripheral vascular disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition. The assessment listed the resident as requiring extensive to total assistance for locomotion on and off the unit. Review of Resident #239's care plan dated 08/15/19 revealed the resident utilized a tilt in space wheelchair. Observation on 10/22/19 at 2:41 P.M. of Resident #239 revealed the resident sitting up in tilt in space wheelchair with no head support on the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2018-09-13 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medial record review, observation, and review of facility policy the facility failed to ensure residents with indwelling catheters had their catheters managed in a dignified manner. This affected one Resident (#147) of four reviewed for activity of daily living (ADL) care. The facility identified 41 residents as having indwelling catheters. In addition, the facility failed to ensure dependent residents were dressed on a daily basis. This affected one Resident (#352) of four reviewed for ADL care. The facility identified 24 residents as being dependent for dressing. The facility census was 392. Findings Include: 1. Review of Resident #147's medical record revealed an admission date of 12/04/16. Diagnoses included hyperlipidemia, chronic atrial fibrillation, hypertension, major depressive disorder, hemiplegia, dysphagia, and anxiety disorder. Review of Resident #147's Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact. Resident #147 required extensive assistance with…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2018-09-13 · 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 medical record review, observation, and review of facility policy the facility failed to ensure residents who required staff assistance with activities of daily living (ADL), received adequate care. This affected one Resident (#147) of four residents reviewed for ADLs. The facility census was 392. Findings Include: Review of Resident #147's medical record revealed an admission date of 12/04/16. Diagnoses included hyperlipidemia, chronic atrial fibrillation, hypertension, major depressive disorder, hemiplegia, dysphagia, and anxiety disorder. Review of Resident #147's Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact. Resident #147 required extensive assistance with transfer, dressing, and personal hygiene. Resident #147 was totally dependent on staff for toilet use and required supervision, set up only, for eating. Resident #147 displayed the behavior of rejecting care one to three days out of the review period. Review of Resident #147's care plan updated 07/18/18 revealed…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2018-09-13 · 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 medical record review, observation, staff interview and facility work instructions, the facility failed to ensure indwelling urinary catheter care was provided accordingly. This affected one Resident (#17) of three reviewed for indwelling urinary catheter use. The facility identified 42 current residents with indwelling urinary catheters in a facility census of 392. Findings include: Resident #17 was admitted to the facility on [DATE] with diagnosis including, dementia, hypertension, benign prostatic hyperplasia, urethral stricture, urinary retention, coronary artery disease, neuromuscular dysfunction of the urinary bladder, and congestive heart failure. According to the most current minimum data set (MDS) assessment dated [DATE] the resident was identified with severe cognitive impairment, dependent on staff for the completion of activities of daily living (ADL's) and utilized an indwelling urinary catheter. According to the medical record on 10/06/16 a physician order for the placement of an…

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

    Quality of Life and Care 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.

Who owns this facility

Owner / managerTypeRoleSince
STATE OF OHIO OFFICE OF BUDGET AND MANAGEMENT STATE ACCOUNTINGOrganizationDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 02/28/2003
ORCHOWSKI, PAULAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/14/2015
REBER, KAITLINIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/23/2026
WACHTEL, BRENDAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/12/2025
RAMEY, JOHNIndividualADP OF THE SNFsince 03/26/2025

CMS files one row per role, so the 9 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

1 organizational owner 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.

Net patient revenuemost recent cost report
Operating marginrevenue minus expenses

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$628per resident / day
operating cost
$19,076per month
≈ monthly operating cost
not reportedthis home filed no revenue line
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in OH

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 366325. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-01-11, 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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