Momentous Health At Sidney
510 Buckeye Ave, Sidney, OH 45365 · For profit - Limited Liability company · 51 certified beds · (937) 492-3171 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
- nursing-staff turnover (57%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 4.9% | 5.3% | 15.4% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 0.7% | 6.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.2% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.4% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 76.8% | 30.1% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.1% | 3.2% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 4.0% | 6.1% | 16.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 28.3% | 25.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 97.5% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.9% | 3.4% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 20.3% | 21.4% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 0.0% | 8.8% | 17.1% | check this* — see note marked star below the table |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 78.3% | 75.6% | 79.4% | typical |
| Long-stay hospitalizations per 1,000 resident days | 0.59 | 1.73 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.66 | 1.80 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.11 therapist hours per resident per day in 2026Q1 — more than 7% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 10% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not 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 SNF | 9.8%CMS range 6.6–16.1 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not 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 SNFs | 1.04 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 51 beds and averages 43.2 residents a day — about 85% occupied, or roughly 8 beds typically open. It usually has some room. 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 3.83 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.42 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.47 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 3.43 hrs/resident/day on weekends vs 3.99 on weekdays — 14% thinner on weekends. RN hours go from 0.43 to 0.38 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 57% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.
- Potential for harm · D2026-03-12 · tag F0825 — isolatedProvide or get specialized rehabilitative services as required for a resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to provide speech therapy as ordered. This affected two (#129 and #130) of three residents reviewed for therapy services. The facility census was 46. Findings include: 1. Review of Resident #129's medical record revealed an admission date of 11/10/21 with diagnoses including dysphagia, dementia, and rheumatoid arthritis. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #129 had severe cognitive impairment and required supervisory support from staff for eating, positioning, and transferring. He was independently mobile using a manual wheelchair. Review of physician orders revealed Resident #129 was to continue his current speech therapy plan of care under a new provider effective 02/01/26. Review of Speech Therapy Transitional Evaluation and Plan of Treatment revealed Resident #129 was to receive speech therapy services twice weekly for four weeks during the certification period 02/01/26 - 02/28/26. Short-term goals…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-06-02 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, observation, staff interview, review of camera footage, review of facility investigation, and review of facility in-services, the facility failed to ensure staff practiced proper infection control practices. This affected one (#01) of three residents reviewed for infection control. This had the potential to affect six additional residents (#04, #08, #11, #21, #29, and #39) identified as being in Enhanced Barrier Precautions (EBP). The facility census was 40. Findings include: Review of the medical record of Resident #01 revealed an admission date of 12/07/23. Diagnoses include quadriplegia and a history of pressure ulcers to buttocks. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #01 was cognitively intact and dependent on staff for personal hygiene and transfers. Resident #01 was assessed as having an indwelling urinary…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-04-10 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview and facility policy review, the facility failed to ensure handwashing or sanitizing was completed between dirty to clean surfaces. This affected six (#39, #5, #23, #41, #28 and #37) out of six residents reviewed for handwashing. The census was 42. Findings included: Observations made on 04/10/25 at 7:42 A.M. during a meal service revealed Activities Director (AD) #63 delivered a breakfast tray to Resident #39 and came out of the room opened the cart and got another tray and went into Resident #5's room and opened the lids for the meal. She went out of the room and got another tray off of the cart and delivered it to Resident # 23's room, left that room and went down the hall to the kitchen to grab a milk for Resident #23. AD #63 proceeded to leave the 100 hall and went down to the 200 hall and proceeded to pass trays to Resident #41 and left the room and went to the cart and got a tray and delivered it to Resident #41 and left the room and went back to the dietary cart and got a tray for Resident #28 and entered the room and touched the resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-10 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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 observation, medical record review, staff and resident interview and facility policy review the facility failed to ensure shaving was completed when the resident had long hairs under her arms and on her legs. This affected one (#39) of one reviewed for dignity and respect. The census was 42. Findings included: Medical record review for Resident #39 revealed an admission date of 10/15/21. Medical diagnoses included chronic obstructive pulmonary disease (COPD), diabetes, cerebrovascular accident (CVA), seizure disorder, anxiety, depression, bipolar disorder, and asthma. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 was cognitively intact. Her functional status was set up or clean up assistance for eating, partial assistance/moderate assistance for toileting, bed mobility, and transfers. She was frequently incontinent for the bladder and always incontinent for the bowel. Review of the shower sheet for Resident #39 dated 04/07/25 revealed shaved was checked…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-10 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff and resident interview, and facility policy review the facility failed to ensure reporting to the state agency was completed when an allegation of abuse was made by a resident. This affected one (#39) of one resident reviewed for reporting an allegation of abuse to the state agency. The census was 42. Findings included: Medical record review for Resident #39 revealed an admission date of 10/15/21. Medical diagnoses included chronic obstructive pulmonary disease (COPD), diabetes, cerebrovascular accident (CVA), seizure disorder, anxiety, depression, bipolar disorder, and asthma. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 was cognitively intact. Her functional status was set up or clean up assistance for eating, partial assistance/moderate assistance for toileting, bed mobility, and transfers. She was frequently incontinent for the bladder and always incontinent for the bowel. Review of the progress notes dated 04/01/25…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-10 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff and resident interview, and facility policy review the facility failed to ensure an investigation into an allegation of abuse was completed. This affected one (#39) of one resident reviewed allegation of abuse. The census was 42. Findings included: Medical record review for Resident #39 revealed an admission date of 10/15/21. Medical diagnoses included chronic obstructive pulmonary disease (COPD), diabetes, cerebrovascular accident (CVA), seizure disorder, anxiety, depression, bipolar disorder, and asthma. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #39 was cognitively intact. Her functional status was set up or clean up assistance for eating, partial assistance/moderate assistance for toileting, bed mobility, and transfers. She was frequently incontinent for the bladder and always incontinent for the bowel. Review of the progress notes dated 04/01/25 revealed there wasn't any evidence concerning an abuse allegation. Interview with Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-10 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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, staff and resident interview, medical record review and facility policy review the facility failed to ensure a resident was changed in a timely manner. This affected one (#39) of three residents reviewed for incontinence care. The census was 42. Findings included: Medical record review for Resident #39 revealed an admission date of 10/15/21. Medical diagnoses included chronic obstructive pulmonary disease (COPD), diabetes, cerebrovascular accident (CVA), seizure disorder, anxiety, depression, bipolar disorder, and asthma. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 was cognitively intact. Her functional status was set up or clean up assistance for eating, partial assistance/moderate assistance for toileting, bed mobility, and transfers. She was frequently incontinent for the bladder and always incontinent for the bowel. Review of the care plan dated 02/06/25 revealed Resident #39 was at risk for bladder incontinence. Interventions included if…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-10 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff and resident interview, and policy review the facility failed to ensure fluid restriction was followed. The affected one (#33) of three residents reviewed for fluid restriction. The census was 42. Findings included: Medical record review for Resident #33 revealed an admission date of 10/13/20. Medical diagnosis included heart failure, hypertension and diabetes. Review of the physician orders dated 12/03/24 revealed 2,000 ml fluid restriction in a 24-hour period for congested heart failure (CHF). Dietary 1080 ml, (breakfast 480 ml, lunch 360 ml, dinner 240 ml) nursing department 920 ml in a 24-hour period (days 500 ml and nights 420 ml) to be documented every shift. Review of the care plan dated 12/03/24 revealed Resident #33 had a potential for fluid imbalance. Interventions were to provide assistance/encouragement/supervision with fluid intake to meet the daily requirements. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #33 was moderately…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-10-17 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, and policy review, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner and food was stored in a safe manner. This had the potential to affect all 38 residents who received food from the kitchen with the exception of one (#05) resident who the facility identified as receiving nothing by mouth from the kitchen. The census was 39. Findings include: Observation on 10/15/24 at 8:37 A.M., during the tour of the kitchen, revealed the ice maker had debris on the outside, top of the ice holding area. Observation inside the ice machine revealed a brownish-red substance was noted above the ice dispensing chute. Observation inside of a small chest freezer, designated to hold residents' private foods, had a moderate amount of ice build-up. The ice extended from the rim to approximately eight inches down and the small inner basket was unable to be moved. The freezer contained five individually wrapped breakfast sandwiches, an opened bag of tater tots, and numerous boxes of various frozen deserts. The food was not dated nor…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-10-17 · tag F0837 — widespreadEstablish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
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 online verification system of the Board of Executives of Long-Term Services and Supports (BELTSS), review of the Administrator job description, staff interview, and facility corrective action, the facility failed to ensure there was a licensed nursing home administrator (LNHA) with a valid license providing supervision and leadership to the facility. This had the potential to affect all 39 residents residing in the facility. The facility census was 39 residents. Findings include: Interview on [DATE] at with Administrator #280 confirmed she served as the facility LNHA of record since [DATE]. Administrator #280 confirmed she was notified by a BELTSS representative that her LNHA license expired on [DATE]. Administrator #280 confirmed Administrator #285, who was employed by the facility corporation, served as LNHA for the facility from [DATE] until [DATE]. Administrator…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 15 citations
- Potential for harm · F2024-10-17 · tag F0868 — widespreadHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of Quality Assurance and Performance Improvement (QAPI) attendance logs, staff interview, and policy review, the facility failed to ensure the facility Medical Director or designee attended QAPI meetings quarterly as required. This had the potential to affect all 39 residents residing in the facility. The facility census was 39. Findings include: Review of the facility quarterly QAPI attendance logs revealed the Medical Director or his/her designee did not attend the quarterly meeting on 04/23/24. Interview on 10/17/24 at 3:25 P.M. with the Director of Nursing (DON) confirmed the facility did not have documentation to confirm the Medical Director or his/her designee attended the quarterly QAPI meeting on 04/23/24. Review of the facility policy titled, QAPI Committee Meetings, dated 05/01/24, revealed the meetings are to ensure the facility care practices maintain standards of quality and to improve the delivery of services and resident outcomes, the facility has established an ongoing Quality Assurance/Quality Improvement (QA/QI) program. Further review revealed the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-17 · tag F0638 — isolatedAssure that each resident’s assessment is updated at least once every 3 months.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, staff interview, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User Manual, the facility failed to ensure quarterly Minimum Data Set (MDS) assessments were completed within required timeframes. This affected three (#2, #9, and #26) of 12 residents reviewed for MDS assessments. The facility census was 39. Findings include: 1. Review of the medical record for Resident #26 revealed an admission date of 11/09/15 with medical diagnoses of dementia, cerebral infarction, Alzheimer's disease, delusional disorders, and schizophrenia disorder. Review of the medical record for Resident #26 revealed a quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 09/07/24. Further review of the MDS assessment indicated Resident #26 had moderate cognitive impairment and required substantial/maximum staff assistance with toileting hygiene and bathing, and supervision with bed mobility and transfers. The MDS assessment had a completion date of 09/24/24. 2.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-17 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User Manual, the facility failed to ensure Minimum Data Set (MDS) assessments were transmitted to CMS as required. This affected one (#94) of 12 residents reviewed for MDS assessments. The facility census was 39. Findings include: Review of the medical record for Resident #94 revealed an admission date of 01/30/23 with medical diagnoses of chronic obstructive pulmonary disease, diabetes mellitus, anemia, hypertension, and moderate protein calorie malnutrition. Review of the medical record for Resident #94 revealed no documentation to support the facility transmitted Minimum Data Set (MDS) assessments timely for an annual MDS assessment dated [DATE], a significant change MDS assessment dated [DATE], a quarterly MDS assessment dated [DATE], and a quarterly MDS assessment dated [DATE]. Interview on 10/16/24 at 9:06 A.M. with MDS Nurse…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-17 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and staff interviews, the facility failed to follow physician orders to ensure treatments were in place. This affected one (#9) of one residents reviewed for treatment of skin conditions. The facility census was 39. Findings included: Review of the medical record for Resident #9 revealed an admission date of 06/11/20 with diagnoses of peripheral vascular disease and venous insufficiency. Review of Resident #9's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, was independent with eating and ambulating, required set-up assistance with oral hygiene, required supervision with bed mobility and transfers, and required partial assistance with toileting hygiene, bathing, dressing, and personal hygiene. Review of the care plan, dated 03/04/24, revealed Resident #9 had potential impairment to skin integrity related to decreased mobility with a goal to be free from injury through the review date. An intervention included to ensure…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-17 · tag F0770 — failed to provide lab services — isolatedProvide timely, quality laboratory services/tests to meet the needs of residents.
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 and staff interview, the facility failed to obtain laboratory testing as ordered by the physician. This affected three (#11, #26, and #28) of three residents reviewed for laboratory values. The facility census was 39. Findings include: 1. Review of the medical record for Resident #28 revealed an admission date of 08/08/19. Diagnoses include chronic obstructive pulmonary disease, essential hypertension, vascular syndromes of the brain in cerebrovascular diseases, vitamin B12 deficiency anemia, heart failure, major depressive disorder, cerebral atherosclerosis, and cerebral infarction. Review of Resident #28's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 was cognitively intact. Review of Resident #28's physician order dated 07/06/21 revealed a complete metabolic panel (CMP), lipid panel, and complete blood count (CBC) with differential was to be obtained every six months on the second Tuesday in June and December. Review of the laboratory results for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-17 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and policy review, the facility failed appropriately perform hand hygiene to maintain proper infection control practices during dressing changes. This affected one (#12) of one residents reviewed for wound care. The facility census was 39. Findings include: Review of the medical record for Resident #12 revealed an admission date of 12/07/23 with diagnoses of quadriplegia, cervical disc disorder with myelopathy, unspecified cervical region, and neuromuscular dysfunction of bladder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 was cognitively intact and was dependent on staff assistance with eating, oral hygiene, toileting hygiene, bathing, dressing, personal hygiene, bed mobility, and transfers. Review of Resident #12's physician orders revealed an order dated 12/08/23 to wash around the suprapubic catheter site with soap and water daily and apply a drainage sponge daily. Review of Resident #12's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-14 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, medical record review, review of video surveillance, staff interview and review of facility policy, the facility failed to ensure gloves were worn during resident care. This affected one (#27) of three residents reviewed for incontinence care. The facility census was 45. Findings include: Review of Resident #27's medical record revealed an admission date of 12/27/23. Diagnoses included quadriplegia, cervical disc disorder with myelopathy, neuromuscular dysfunction of the bladder, anxiety disorder and transient cerebral ischemic attack. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 was cognitively intact and required full assistance for personal hygiene and transfers. Interview on 08/14/24 at 11:00 A.M. with Resident #27 revealed on or about 06/26/24, a female employee touched his genitalia with ungloved hands while providing care. Review of video surveillance of Resident #27's room, dated 06/26/24 and timestamped at 8:14 P.M., revealed a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2022-02-24 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, review of dishwasher logs, and review of the facility Dish Machine Guidelines, the facility failed to ensure the dishwasher was operating correctly. This had the potential to effect all 41 residents who recieved food from the kitchen. Resident #2 did not receive food from the kitchen. The facility census was 42. Findings include: Observation on 02/22/22 at 9:00 A.M. revealed the dishwasher was a high-temperature sanitizer. The rinse cycle revealed a high temperature of 170 degrees Fahrenheit (F). A second observation at 9:05 A.M. with Dietician #161 revealed the rinse cycle attained a temperature of 172 degrees F. Review of the dish machine temperature logs for 01/22/ and 02/22 revealed 31 entries with a rinse temperature less than 180 degrees F. Interview on 02/22/22 at 9:10 A.M. with Dietary Personnel (DP) #107 revealed the temperature of the rinse cycle should be above 180 degrees F and she records the temperature with breakfast trays and lunch trays. DP #107 stated she does not inform anyone if the temperature is below 180 degrees F.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-02-24 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, medical record review, and review of facility policy, the facility failed to ensure staff appropriately removed personal protective equipment (PPE) when exiting the room of a resident under transmission precautions (TBP). This affected one (#30) of three residents reviewed for TBP and had the ability to affect 15 residents (#1, #2, #6, #12, #13, #16, #18, #19, #20, #22, #28, #37, #38, #43, and #195) residing on the 200 hall. The census was 42. Findings include: Review of Resident #30's medical record revealed an admission date of 10/15/21. Diagnoses included bipolar disorder, schizophrenia, major depressive disorder, and acute bronchitis. Resident #30 was assessed as being cognitively intact and requiring limited assistance to supervision with activities of daily living (ADLs). Review of physician order dated 02/21/22 revealed Resident #30 was to be on droplet isolation related to left infiltrate and contact isolation to left infiltrate every shift until 03/04/22. Observation on 02/23/22 at 8:41 A.M. revealed Licensed Practical Nurse (LPN) #112 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.
- Potential for harm · Dcited before2022-02-24 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review and staff interview, the facility failed to accurately complete Minimum Data Set (MDS) assessments for three (#29, #33, and #34) of 12 residents in the survey sample. The census was 42. Findings include: 1. Review of Resident #34's medical record revealed an admission date of 02/24/20. Diagnoses included chronic diastolic heart failure, type II diabetes mellitus, atrial fibrillation, and anemia. Review of a annual MDS assessment, dated 11/08/21, revealed Resident #34 was coded as receiving an anticoagulant medication for seven days of the look back period. Review of a quarterly MDS assessment, dated 02/02/22, revealed Resident #34 was coded as receiving an anticoagulant medication for seven days of the look back period. Review of medication administration records (MARs) for November 2021 through February 2022 revealed no documentation of Resident #34 receiving an anticoagulant medication. Interview on 02/24/22 at 8:56 A.M., Licensed Practical Nurse (LPN) #157 confirmed Resident #34's MDS assessments an 11/08/21 and 02/02/22 were coded incorrectly for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-02-24 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
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 an accurate Preadmission Screening and Resident Review (PASARR)was completed. This effected one (#7) of two residents reviewed for PASRR. The facility census was 42. Findings include: Review of the medical record of Resident #7 revealed an admission date of 11/10/21 and a readmission date of 12/16/21. Diagnoses included unspecified dementia with behavioral disturbance and bipolar type schizoaffective disorder. Review of the Preadmission Screening and Resident Review (PASRR) Identification Screen dated 12/14/21 and signed by a Catholic Social Service assessor revealed a no response was documented for the diagnosis of dementia. A negative response was also indicated for a diagnosis of any mental disorder. Interview on 02/24/22 at 9:37 A.M. with Licensed Practical Nurse (LPN) #7 provided verification of the inaccurate assessment.
- Potential for harm · Fcited before2019-05-09 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, policy review and staff interview, the facility failed to maintain an effective Legionella Control procedure. This had the potential to affect all 46 residents residing in the facility. Findings include: Review of an undated facility form titled Identifying Buildings at Increased Risk revealed if the facility answered yes to any questions one through four, they should have a water management program for the building's hot and cold water distribution system. The facility checked yes to questions one, two, and three. Question one-Is your building a healthcare facility where patients stay overnight or does your building house or treat people who have chronic and acute medical problems or weakened immune systems? Question 2-Does your building primarily house people older than 65 years? Question 3-Does your building have multiple housing units and a centralized hot water system? Review of the Legionella Control procedure revealed no monitoring of the water temperatures, water sanitizer or disinfectant levels were documented. Interview on 05/09/19 at 1:00 P.M. with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2019-05-09 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to accurately code Minimum Data Set (MDS) assessments to reflect residents medications used. This affected five (Resident #11, #14, #25 #32 and 36) of 12 residents records reviewed. The facility census was 46. Findings include: 1. Review of medical record for Resident #11 revealed an admission date of 08/16/19 with diagnoses including Alzheimer's disease, major depression, insomnia, diabetes type two, hyperlipidemia, hypertension, hypothyroidism, muscle weakness, cerebral infarction and low back pain. Review of discharge return anticipated MDS assessment for Resident #11 with an assessment reference date (ARD) of 04/11/19 documented she was assessed as receiving anticoagulant medication seven days during the look back period of the set ARD. Review of monthly medication administration record (MAR) for April 2019 revealed the resident had a current physician order for Plavix (antiplatelet) medication and was administered the medication…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-05-09 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — the official record, unedited, may be distressing
Based on medical record review and staff interview, the facility failed to ensure care plans addressed all resident care areas. This affected one resident (#24) of 11 reviewed for care plans. The facility census was 46. Findings include: Review of the medical record of Resident #24 revealed an admission date of 04/02/19. Diagnoses include chronic obstructive pulmonary disease, essential hypertension acute on chronic diastolic heart failure, anemia, and stage four chronic kidney disease. Review of the care plan dated 04/04/19 revealed it to be silent of any dialysis care. Review of the physician order dated 04/10/19 revealed an order for Resident #32 to be transported to dialysis center on Tuesday, Thursday and Saturday. Interview on 05/08/19 at 10:43 A.M. provided verification of the lack of dialysis care plan.
- No harm found · C2025-12-03 · tag F0803 — failed to meet residents' dietary needs — widespreadEnsure 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 observations, staff and resident interviews, and review of the facility weekly menus, the facility failed to ensure sufficient supply of coffee was available for residents as per the facility menu and failed to ensure menus were available for resident review. This had the potential to affect 38 out of 38 residents who receive meals from the kitchen, the facility identified one (#13) who does not receive meals from the kitchen. The facility census was 39. Findings include: Review of the facility's weekly menu contained documentation to support coffee would be offered daily with breakfast. Further review revealed of the weekly menu revealed documentation for alternate vegetable and assorted dessert but did not specify what vegetable or dessert was to be served for lunch or supper. Observations on 12/02/25 at 8:50 A.M. revealed the weekly or daily menu was not posted/displayed in the dining area or common areas for residents to review. Interview on 12/02/25 at 8:58 A.M. with Resident #22 stated he was not offered coffee with his breakfast that morning. Interview on 12/02/25 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| STEIN, MARK | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; ADP OF THE SNF | 50% | since 05/01/2022 |
| TENENBAUM, MICHAEL | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; ADP OF THE SNF | 50% | since 02/01/2022 |
| WALTER, MANDY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/15/2024 |
| TOPALOV, MIGUEL | Individual | ADP OF THE SNF | — | since 10/01/2024 |
CMS files one row per role, so the 9 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 74% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $219K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OH
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Ohio Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 366033. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-10-17, 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.