Solon Pointe At Emerald Ridge
5625 Emerald Ridge Parkway, Solon, OH 44139 · For profit - Limited Liability company · 99 certified beds · (440) 498-3000 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- it has a citation for mishandling residents’ money or property (F0567)
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $10,845 in federal fines (most recent 2024-05-16)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- nursing-staff turnover (58%) 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) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 6.7% | 5.3% | 15.4% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 5.7% | 6.2% | 5.4% | typical |
| 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 | 0.0% | 30.1% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.5% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 4.1% | 6.1% | 16.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 21.6% | 25.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 94.0% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.9% | 3.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 20.7% | 21.4% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 7.9% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.8% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 82.7% | 75.6% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 36.1% | 24.9% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 12.6% | 12.9% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 3.19 | 1.73 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.75 | 1.80 | 1.80 | typical |
* 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.
30.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 32 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 66.7% 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 30 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 0.39 therapist hours per resident per day in 2026Q1 — more than 67% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 41% 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 | 30.2%CMS range 18.3–45.0 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.0%CMS range 8.3–17.4 | 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 | 66.7% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 56.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 53.3% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 88.6% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.4% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.6%CMS range 4.0–12.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.18 | 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 99 beds and averages 88.5 residents a day — about 89% occupied, or roughly 10 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.25 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.68 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.44 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.83 hrs/resident/day on weekends vs 4.41 on weekdays — 13% thinner on weekends. RN hours go from 0.74 to 0.53 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 58% 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.
30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.
- Immediate jeopardy · Jcited before2024-05-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record review, staff interview, family interview, review of the facility resident census, review of staff schedules, review of police records, review of the facility policy on Wandering, Unsafe Residents, review of the facility's investigation, review of information on the Weather Underground computerized environmental temperatures website, review of Google Maps, and review of the facility's elopement book, the facility failed to prevent the elopement of a cognitively impaired resident (Resident #70), with a history of attempted elopement and who was assessed to be at risk for elopement from the facility. This resulted in Immediate Jeopardy and the potential for serious life-threatening injuries, negative health outcomes and/or death, when Resident #70 left the facility through an alarmed elevator (that did not alarm/sound), without staff knowledge, and was found by a tenant at a previous residence, 1.4 miles from the facility which was down a two-lane road with a center turn lane…
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 · F2026-01-08 · tag F0804 — failed to serve food at safe, palatable temperature — widespreadEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, medical record review, resident and staff interview, review of a menu, and facility policy review, the facility failed to ensure food was palatable and served at acceptable temperatures. This affected directly affected (#61 and #88) of two residents reviewed for food concerns and had the potential to affect all residents receiving meals from the kitchen. The facility indicated there were three (#44, #66, and #102) residents who received nothing by mouth. The facility census was 92.Findings include:1. Review of the medical record for Resident #61 revealed an admission date of 12/11/25. Diagnoses included but were not limited to hypokalemia, ulcerative colitis, and gastro-esophageal reflux disease.Review of the 12/18/25 admission Minimum Data Set (MDS) assessment for Resident #61 revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated the resident had intact cognition. Resident #61 was noted to require set up for meals and receive a regular diet.Review of the physician orders for Resident #61 revealed an order dated 12/13/25 for a regular…
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 · E2026-01-08 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, medical record review, staff interview, review of facility menus, review of facility production sheets, review of food substitution logs, and review of facility policies, the facility failed to ensure all menu items were provided for all residents, specifically residents with an order for a pureed diet. This directly affected one (#41) of four residents reviewed for food and nutrition with potential to affect seven (#9, #16, #55, #59, #68, #81, and #100) additional residents who received a pureed diet. The facility census was 92.Findings include:Review of the medical record for Resident #41 revealed an admission date of 09/05/24. Diagnoses included but were not limited to polyneuropathy, hyperlipidemia, noninfective gastroenteritis and colitis, and sarcoidosis. Review of the 11/14/25 significant change Minimum Data Set (MDS) assessment for Resident #41 revealed a Brief Interview of Mental Status (BIMS) score of four which indicated the resident had severe cognitive impairment. Review of activities of daily living (ADLs) for Resident #41 revealed she required…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-08 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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 record review, resident interview, staff interview, and facility policy review, the facility failed to ensure residents advance directives were accurately documented in the resident medical record. This affected one (#88) of one resident reviewed for advanced directives. The facility census was 92. Findings include:Review of the electronic medical record (EMR) for Resident #88 revealed he was admitted to the facility on [DATE] with diagnoses that included cerebral palsy, dysarthria and anarthria, and ataxia. Review of the EMR revealed Resident #88 was a full code status (cardiopulmonary resuscitation (CPR) would be initiated in an event of cardiac or respiratory arrest). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #88 had a Brief Interview for Mental Status (BIMS) score of 15, indicting the resident was cognitively intact. Review of the MDS assessment revealed Resident #88 required some assistance for activities of daily living (ADLs).Review of the care plan…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-08 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to ensure a resident's Preadmission Screening and Resident Review (PASRR) accurately reflected current mental health conditions. This affected one (#8) of three residents reviewed for PASRR. The facility census was 92.Findings include:Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, post-traumatic stress disorder (PTSD), and major depressive disorder. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was cognitively intact and required assistance of one staff person for completing her activities of daily living.Review of the Preadmission Screening and Resident Review (PASRR) document dated 01/19/24, under section E titled, Indications of Serious Mental Illness, revealed the facility did not provide/document indications that the resident had a diagnosis of post-traumatic stress…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-08 · 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 — 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 develop and implement a comprehensive, person-centered care plan to address a resident's healthcare needs. This affected one (#8) of one residents reviewed for post-traumatic stress disorder. The facility census was 92.Findings include:Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, post-traumatic stress disorder (PTSD), and major depressive disorder. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was cognitively intact and required assistance of one staff person for completing her activities of daily living.Review of the current comprehensive care plan for Resident #8 revealed no problems, goals, or interventions related to Resident #8's PTSD.Social Service Director (SSD) #701 verified in an interview on 01/08/26 at 8:45 A.M. that Resident #8's care plan did not address Resident #8'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 · D2026-01-08 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, hospital document review, review of fall investigations, resident representative interview, staff interview, and policy review, the facility failed to ensure resident care plans were revised to reflect residents' current medical and psychological status and resident representatives were provided the option to chose care and treatment interventions during care plan development. This affected two (#22 and #82) of twenty-two sampled residents. The facility census was 92.Findings include:1. Review of Resident #22's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, bipolar type; dementia with psychotic disturbance; and cognitive communication deficit. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was cognitively intact, required hands-on assistance for activities of daily living, and had no documented behaviors. Review of Resident #22's care…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-08 · 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, medical record review, review of shower sheets and schedules, resident interview, resident representative interview, staff interview, and facility policy review, the facility failed to ensure residents were provided with appropriate care and assistance with their activities of daily living. This affected three (#10, #25, and #73) of three residents reviewed for activities of daily living. The census was 92. Findings include:1. Review of the medical record for Resident #73 revealed an admission date of 07/11/25. Diagnoses included Parkinsonism, dementia, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment revealed the resident was cognitively intact. She required supervision/touching assistance for eating. Review of the January 2026 physician orders revealed orders for a divided plate, weight utensils, and a sippy cup with lid and straw. Review of the care plan initiated on 07/23/25 revealed Resident #73 had a goal to maintain activities of daily living (ADLs).…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, hospital document review, review of fall investigations, resident representative interview, staff interview, and policy review, the facility failed to ensure appropriate fall interventions were implemented and consistently in place to prevent falls. This affected one (#82) of three residents reviewed for falls. The facility census was 92.Findings include:Review of the medical record for Resident #82 revealed he was admitted to the facility on [DATE] with diagnoses that included anoxic brain damage, intracranial injury, post traumatic seizures, and spastic quadriplegic cerebral palsy. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 00, that indicated Resident #82 had severe cognition impairment. Review of the MDS assessment revealed Resident #82 was dependent on staff for activities of daily living (ADLs). Review of the care plan dated 05/19/25 revealed Resident #82 had increased risk for falls…
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 · D2026-01-08 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure medications were administered as ordered to prevent a medication error rate of less than five (5) percent (%). A total of two medication errors were observed out of 29 opportunities for a medication error rate of 6.9%. This affected one (#57) of four residents observed for medication administration. The census was 92. Findings include:Review of Resident #57's medical record revealed he was admitted [DATE] and had diagnoses including unspecified dementia, paranoid schizophrenia, and chronic gout. Review of Resident #57's physician orders revealed the resident was ordered fish oil 1200 milligrams (mg) once daily on 10/20/23, and was ordered vitamin D3 on 06/07/23 with instructions to give one tablet daily but had no dosage specified. Observation of a medication administration for Resident #57 by Licensed Practical Nurse (LPN) #840 on 01/07/25 at 9:02 A.M. revealed she administered one 1000 unit pill of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-22 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility failed to ensure a resident's call light was accessible to request assistance as needed. This affected one (#28) of four resident's observed for accommodation of needs. The facility census was 88. Findings include: Review of the medical record for Resident #28 revealed an admission date of 05/15/23. Diagnoses included chronic respiratory failure, hemiplegia affecting left nondominant side, morbid severe obesity, major depressive disorder, anxiety, tracheostomy, and dependence on respirator. Review of the Annual MDS assessment dated [DATE] revealed Resident #28 was cognitively intact. Resident #28 had no impairment of the upper or lower extremities. Resident #28 used no mobility devices. Resident #28 required assistants with activities of daily living. Review of the care plan for Resident #28 dated 02/15/24 revealed Resident #28 was at risk for falls related to deconditioning, confusion, gait/balance problems, and incontinence. Interventions…
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 19 citations
- Potential for harm · D2024-05-22 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, family interview, staff interview, record review, and review of policy, the facility failed to timely implement measure to promote mobility of a resident, who required a specialized wheelchair to be evaluated by therapy services to obtain a customized wheelchair. This affected one (#28) of three residents reviewed for mobility. The facility census was 88. Findings include: Review of the medical record for Resident #28 revealed an admission date of 05/15/23. Diagnoses included chronic respiratory failure, hemiplegia affecting left nondominant side, morbid severe obesity, major depressive disorder, anxiety, tracheostomy, and dependence on respirator. Resident #28 had a payer source of Medicaid. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 was cognitively intact. Resident #28 had no impairment of the upper or lower extremities. Resident #28 used no mobility devices. Resident #28 was set up or clean up assist with eating and oral…
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 · D2024-05-22 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure oxygen orders were obtained including the liters to be administered and the frequency of administration. This affected one (#18) of three residents reviewed for respiratory services. The facility census was 88. Findings include: Review of the medical record for Resident #18 revealed an admission date of 08/20/21. Diagnoses included chronic obstructive pulmonary disease and unspecified glaucoma. Review of the significant change Minimum Data Set (MDS) dated [DATE] for Resident #18 revealed Resident 18 was moderately cognitively impaired. Resident #18 received oxygen therapy. Review of the care plan for Resident #18 dated 07/13/23 revealed Resident #18 was at risk for developing complications secondary to has oxygen therapy related to respiratory illness. Review of the physician order dated 02/22/24 for Resident #18 revealed an order Respiratory Therapy to evaluate and treat as indicated. Review of the Respiratory Therapy note dated 02/23/24…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-22 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
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, staff interview, and review of policy, the facility failed to monitor a resident's blood pressure prior to the administration of medication per physician orders. This affected one (#93) of three residents reviewed for assessment prior to medication administration. The facility census was 88. Findings include: Review of the medical record for Resident #93 revealed an admission date of 01/14/23 and a discharge date of 04/13/24. Diagnoses included chronic obstructive pulmonary disease (COPD), chronic combined systolic congestive and diastolic congestive heart failure (CHF), and essential primary hypertension. Review of the quarterly Minimum data set (MDS) dated [DATE] revealed Resident #93 required assistants with activities of daily living and had cardiorespiratory conditions. Review of the care plan for Resident #93 revealed Resident #93 was a full code. Resident #93 had hypertension interventions which included giving medications as ordered, monitoring side effects, and monitoring 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 · D2024-05-22 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, transport timeline review and review of policy, the facility failed to ensure documentation was complete in the resident medical record. This affected one (#85) of three residents medical records reviewed for documentation. The facility census was 88. Findings include: Review of the medical record for Resident #85 revealed an admission date of 01/22/24. Diagnoses included cerebral palsy, chronic obstructive pulmonary disease, tracheostomy, and chronic respiratory failure. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #85 had severe cognitive impairment and was impaired on one side of the upper and lower extremity. Resident #85 was dependent for activities of daily living. Resident #85 had medically complex conditions, which included cerebral palsy, chronic respiratory failure with hypoxia, tracheostomy, oxygen therapy, and suctioning. Review of the care plan dated 01/29/24 revealed Resident #85 was at risk for alteration in code status,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-22 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and staff interview, resident interview, the facility failed to timely repair one resident's wall with several large visible holes, dents, and scrape markings on it. This affected one (#28) of three residents reviewed for the environment. The facility census was 88. Findings include: Review of the medical record for Resident #28 revealed an admission date of 05/15/23. Diagnoses included chronic respiratory failure, hemiplegia affecting left nondominant side, morbid severe obesity, major depressive disorder, anxiety, tracheostomy, and dependence on respirator. Review of the Annual Minimum Data Set (MDS) assessment, dated 03/14/24, revealed Resident #28 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15 (cognitively intact). Resident #28 had no impairment of the upper or lower extremities. Resident #28 used no mobility devices. Resident #28 had no behavior exhibited and no rejections of care. Observation on 05/08/24 at 3:22 P.M., revealed the wall behind Resident #28's headboard had three very large holes that reached from outside both sides of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-01-12 · tag F0761 — failed to label and store drugs safely — widespreadEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, and policy review the facility failed to ensure that all drugs and biologicals used in the facility were accurately labeled in accordance with professional standards to facilitate safe medication administration. This had the potential to affect all residents who reside in the facility. The facility census was 78. Findings include: Observation with the Director of Nursing (DON) on 01/10/23 at 12:05 P.M., of the medication storage room located on Rust unit, revealed the refrigerator contained one opened Novolog (insulin) flex pen mixed with other resident insulin pens, and without a resident identifier or date opened. Interview with the DON immediately following the observation, revealed the DON was unable to accurately identify the prescribed resident or date opened. The DON verified the medication was not labeled for safe medication administration per the facility policy. Observation with the DON on 01/10/23 at 12:35 P.M., of the medication storage room located on Maple unit, revealed the refrigerator contained a single one milliliter (ml)…
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 before2023-01-12 · tag F0921 — failed to keep a safe, functional, sanitary building — widespreadMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and staff interview the facility failed to maintain a clean and sanitary environment. This had the potential to affect all 78 residents residing in the facility. Findings include: An environmental tour was conducted with Housekeeping Supervisor (HSK) #99 on 01/10/22 between 2:00 P.M. and 2:36 P.M. The following concerns were identified and verified at the time of discovery: • The tube feed pole used by Resident #20 had significant dried residual tube on the base of the pole. • The 700 and 800 halls had mold in the shower rooms. • The rooms occupied by Residents #25, #45 and #55 had tile flooring that was broken. • The hallway air conditioner/heating unit cover on the 700 hall was off and the air conditioner was dirty. • The room occupied by Resident #31 had a dirty and stained privacy curtain. • The toilet paper roll in Resident #229's room was off the wall, and the toilet paper was touching the bathroom floor. • The air vent on the 700 hall was rusted. • The 800-hall dining room had numerous water-stained ceiling tiles. • The bathroom walls in Resident #35'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 before2023-01-12 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and staff interview the facility failed to maintain an accurate medical record (code status) for Resident #45. This affected one resident (#45) of one resident reviewed for advanced directives. The facility census was 78. Findings include: Review of the hard paper medical revealed a green piece of paper stating Resident #45 was a full code (full resuscitative measures including chest compressions would take place in the event of a cardiac arrest or other medical emergency). Review of the electronic medical record revealed Resident #45 was listed as a DNRCC (do not resuscitate comfort care) indicating Resident #45 would only be kept comfortable in the event of a cardiac arrest or similar medical event. Interview on 01/09/23 at 3:33 P.M. Licensed Practical Nurse (LPN) #101 verified that the electronic and paper charts had conflicting code status information. Review of the undated policy titled Advanced Directives revealed The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advanced directives.
- Potential for harm · Dcited before2023-01-12 · 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 — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review the facility failed to ensure Resident #48's care plan included communication and/or sensory deficits. This affected one resident (#48) of one resident reviewed for care planning. The facility census was 78. Findings include: Review of the medical record revealed Resident #48 was admitted to the facility on [DATE] with diagnoses including dementia, severe, with other behavioral disturbance, type two diabetes mellitus without complications, and sensorineural hearing loss, bilateral. Review of the Minimum Data Set 3.0 (MDS) 3.0 assessment dated [DATE] revealed Resident #48 was alert and oriented with some cognitive impairment. Review of Section B of the MDS assessment revealed Resident #48 had moderate difficulty with hearing with a hearing aid device. Review of the Nursing admission and/or re-admission assessment dated [DATE] revealed Resident #48 had moderate difficulty with hearing and utilized a hearing aid in his right ear. Review of the progress…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2019-09-19 · tag F0567 — failed to protect residents' money held by the home — patternHonor the resident's right to manage his or her financial affairs.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, record review and interview, the facility failed to ensure Resident #37 had access to resident funds on weekends. This had the potential to affect 56 residents with active resident accounts. Findings include: Interview on 09/16/19 at 11:16 A.M. with Resident #37 revealed residents with accounts had to get money on Friday for the weekend. Review of the Resident Fund Petty Cash log dated July 2019 to August 2019 were silent for weekend withdrawals. Observation on 09/18/19 at 1:26 P.M. revealed a sign in lobby on receptionist's counter that read banking hours Monday through Friday from 10:00 A.M to 4:00 P.M. Interview on 09/18/19 at 1:34 P.M. with Administrative Staff (AS) #24 and Administrator verified the sign on the receptionist counter and stated going forward residents will have access their funds on the weekends. Review of the facility's policy titled Resident Personal Financial Items, revised January 2018, revealed a personal needs account is available to residents to maintain money in the facility and is available upon request of the resident.
- Potential for harm · E2019-09-19 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to maintain a clean, sanitary and homelike environment. The facility also failed to ensure sufficient towels and wash cloths for resident use. This affected Residents #32, #67 and #22 and had the potential to affect all 84 residents residing in the facility. Findings include: 1. Observations of the resident environment on 09/16/19 at 11:35 A.M. revealed a large window in the hall between rooms [ROOM NUMBERS]. The window sill shelf appeared to be warped and in disrepair. The top portion of the window sill appeared to be removed and partially covered with black colored plastic. Interview on 09/16/19 at 11:37 A.M. with Registered Nurse (RN) #110 revealed the window sill had been like that for three weeks, and she had not seen anyone working on it. Observation at 11:57 A.M. of the paper towel dispenser in Resident #32's bathroom revealed it was broken. Interview on 09/16/19 at 12:11 P.M. with State Tested Nurse Aide (STNA) #123 verified the paper…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2019-09-19 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, the facility failed to ensure proper sanitation and storage of dishes. This had the potential to affect 81 of 84 residents who ate meals in the facility's kitchen. Residents #182, #184 and #232 did not receive anything by mouth. Findings include: Observation on 09/18/19 at 10:09 A.M. of the dish washing machine revealed the machine was a low temperature machine which used a sanitizer and was beeping. Dietary Aide (DA) #49 was asked to test the proper sanitizer concentration of the dish machine and did not know how to test the sanitizer. Dietary Manager #186 and Regional Dietary Manager #185 could not find the test strips and verified the dish machine was beeping. Regional Dietary Manager #185 stated that the chemical company was called and are on the way. A return visit to the kitchen on 09/18/19 at 11:35 A.M. revealed Dish Machine Technician #187 was working on the dish machine and stated that the machine was beeping because no chemicals were going into the machine to clean or sanitize the dishes. The dish machine was operating…
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 · D2019-09-19 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure Resident #44's representative received written notice of transfer to the hospital and bed hold notice. The facility also failed to ensure the long-term care Ombudsman received a copy of the transfers notice. This affected one of one resident reviewed for hospitalization. Findings include: Review of Resident #44 medical record revealed an initial admission date of 07/24/09. Diagnoses included unspecified dementia without behavioral disturbance, schizophrenia, malignant neoplasm of colon unspecified, and Alzheimer's disease with late onset. The significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had impaired cognition and required total dependence of one staff for bed mobility and toilet use and total dependence of two staff for transfers. Review of the nursing note dated 07/14/2019 at 5:52 P.M. revealed a nurse placed a call to the local hospital for an update on Resident #44 and received confirmation that…
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 · D2019-09-19 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure Resident #44's representative received written notice of transfer to the hospital and bed hold notice. This affect one of one resident reviewed for hospitalization. Findings include: Review of Resident #44 medical record revealed an initial admission date of 07/24/09. Diagnoses included unspecified dementia without behavioral disturbance, schizophrenia, malignant neoplasm of colon unspecified, and Alzheimer's disease with late onset. The significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had impaired cognition and required total dependence of one staff for bed mobility and toilet use and total dependence of two staff for transfers. Review of the nursing note dated 07/14/2019 at 5:52 P.M. revealed a nurse placed a call to the local hospital for an update on Resident #44 and received confirmation that the resident was admitted . Review of the local hospital paperwork for Resident #44 revealed 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 · D2019-09-19 · tag F0641 — isolatedEnsure 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 record review and interview, the facility failed to ensure the Minimum Data Set (MDS) 3.0 assessment was coded accurately for Residents #16 and #84. This affected two of 22 residents reviewed for accuracy of assessments. The facility census was 84. Findings include: 1. Record review of Resident #16 revealed an admission date of 01/01/14. Diagnoses included schizophrenia, vascular dementia without behavioral disturbance, and anxiety disorder. The quarterly MDS 3.0 assessment dated [DATE] revealed the resident received antidepressants daily. Review of the June 2019 and July 2019 Medication Administration Record (MAR) revealed Resident #16 did not receive antidepressants. Interview on 09/18/19 at 5:34 P.M. MDS Nurse #82 verified Resident #16 had not received antidepressants, and that the MDS 3.0 assessment dated [DATE] stating the resident received antidepressants was an error. 2. Record review of Resident #84 revealed an admission date of 07/24/19 and a discharge date of 08/05/19 with diagnoses that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-09-19 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interview and policy review, the facility failed to secure medications properly during medication administration. This had the potential to affect one (Resident #57) of 32 resident reviewed for medication administration. Findings Include: Observations on 09/17/19 at 6:28 P.M. revealed a medication cart unlocked and medications in a cup placed on top of the cart. No staff were observed near the cart. Licensed Practical Nurse (LPN) #86 arrived at the cart at 6:23 P.M., observed this writer at cart and verified the unlocked cart and medications sitting on top of medication cart. Review of medications and Medication Administration Record (MAR) revealed medications for Resident #57 including Gabapentin (antiseizure and nerve pain medication), Senna (laxative), Tylenol (pain medication), Lipitor(cholesterol medication), Melatonin (sleep medication), Keppra (antiseizure medication), and Metoprolol (blood pressure medication). Interview during observations, LPN#86 stated that she knew it was wrong to leave medications on top of the unlocked medication cart. LPN#86…
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 · D2019-09-19 · tag F0810 — isolatedProvide special eating equipment and utensils for residents who need them and appropriate assistance.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure consistent use of adaptive equipment for one resident (Resident #46) of eight Residents (#2, #10, #28, #44, #46, #61, #62 and #77) observed for adaptive equipment. The facility census was 84. Findings include: Review of Resident #46's medical record revealed an admission date of 05/14/19 with diagnoses including spinal stenosis, chronic kidney disease, schizoaffective disorder and heart failure. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #46 was cognitively intact and was on a therapeutic diet. Review of Resident #46's meal ticket revealed Resident #46 was on a carbohydrate-controlled diet with adaptive equipment to include built up utensils, two handled sippy cups, and a high sided plate. Observation of lunch meal on 09/18/19 at 12:35 P.M. revealed cups for beverages were located on the top of the food truck. There were plastic coffee mugs and plastic glasses, no sippy cups.…
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 · D2019-09-19 · 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
Based on observations, interview and policy review, the facility failed to adhere to infection control standards for cleaning glucometers. This had the potential to affect five (Residents #26, #31, #40, #46 and #54) of five residents who received blood sugar monitoring. The facility census was 84. Findings Include: Observations on 09/17/19 at 4:27 P.M., Licensed Practical Nurse (LPN) #81 checked a blood sugar for Resident #26, placed the glucometer back in medication cart without sanitizing it. At 4:46 P.M., LPN#81 took the glucometer out of the cart, entered room of Resident #46, and placed glucometer on resident personal side table without sanitizing it. LPN #81, eventually, grabbed the glucometer and cleaned it with an alcohol pad and tested blood sugar. LPN #81 placed glucometer back in medication cart without sanitizing it. Interview during observation, LPN #81 was questioned about policy and procedure for cleaning the glucometer. LPN #81 stated that glucometers were to be cleaned using a Santi wipe (germicidal disposable wipe). LPN #81 stated the glucometer was cleaned with 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.
- No harm found · C2023-01-12 · tag F0814 — failed to dispose of garbage properly — widespreadDispose of garbage and refuse properly.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, staff interview, and facility policy review the facility failed to ensure the dumpster area was maintained in a clean and sanitary condition. This had the potential to affect all residents. The facility census was 78. Findings include: Observation of the dumpster area on 01/11/23 at 2:15 P.M. revealed one dumpster did not have a door to keep closed. The dumpsters were noted to be open exposing the following: • Multiple used gloves, surgical masks, incontinence briefs and pads • Multiple empty brown cardboard boxes, plastic cups, bottles of cleansing liquid • Multiple food scraps, empty potato chips bags and pop bottles Interview on 01/11/23 at 2:15 P.M. with Dietary [NAME] (DC) #46 confirmed the above findings. Review of the facility document titled Waste Disposal, revised January 2012, revealed the facility had a policy in place that all infectious and regulated waste would be handled and disposed of in a safe and appropriate manner. Review of the document revealed the facility did not implement the policy.
“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
$10,845 in federal fines across 1 penalty.
- $10,845 — penalty dated 2024-05-16
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to CCH HEALTHCARE — 33 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.5 | -0.5 vs chain |
| Health inspection | 2 of 5 | 2.4 | -0.4 vs chain |
| Staffing | 3 of 5 | 2.5 | +0.5 vs chain |
| Quality measures | 4 of 5 | 3.9 | +0.1 vs chain |
The other 32 homes this chain runs (chain average 2.5★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| SOLON HOLDING LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 34% | since 01/01/2022 |
| JB EAST END INVESTMENTS, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 7% | since 01/01/2022 |
| BASCH, JOSHUA | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 7% | since 01/01/2022 |
| WEINSTOCK, DAVID | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 7% | since 01/01/2022 |
| KOSTOS, ERIN | Individual | W-2 MANAGING EMPLOYEE | — | since 01/01/2022 |
| STERN, JACOB | Individual | CORPORATE OFFICER | — | since 01/01/2022 |
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 78% 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 $1.0M 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 366179. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-08, 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.