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Northwood Skilled Nursing And Rehabilitation

2000 Villa Road, Springfield, OH 45503 · For profit - Corporation · 85 certified beds · (937) 399-7195 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0603) — cited Jul 2021Behavioral-health or dementia-care citation — no harm found (F0758)1 immediate-jeopardy citation1 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)$34,976 in federal fines
Insights

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

In its favor
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0603), cited Jul 2021
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (39) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $34,976 in federal fines (most recent 2024-06-20)
  • 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 (58%) runs well above the national median (45%)
  • its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions

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

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

2/5
CMS overall
2 of 5
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

Urgent care / clinic
1220 E Home Rd · (937) 342-9590 · Call to confirm hours
Pharmacy
CVS Photo1.0 mi
2987 Derr Rd · (800) 746-7287 · Call to confirm hours
Grocery
Kroger1.0 mi
2989 Derr Rd · (937) 390-2390 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
2177 Emmanuel Way · (937) 471-4048

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

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 4 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.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased6.9%5.3%15.4%worse than state — see note marked double-dagger below the table
Long-stay residents who lose too much weight9.0%6.2%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.2%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.4%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms97.3%30.1%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury5.0%3.2%3.3%worse
Long-stay residents whose ability to walk worsened11.1%6.1%16.1%worse than state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication27.0%25.5%18.9%worse
Long-stay residents given the seasonal flu vaccine97.1%94.5%95.3%typical
Long-stay residents with pressure ulcers4.1%3.4%4.7%better
Long-stay residents with worsening bladder/bowel control22.5%21.4%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table5.1%8.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.9%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine50.7%75.6%79.4%worse
Short-stay residents rehospitalized after admission27.0%24.9%22.6%worse
Short-stay residents with an outpatient ER visit9.7%12.9%12.0%better
Long-stay hospitalizations per 1,000 resident days0.581.731.67better
Long-stay outpatient ER visits per 1,000 resident days1.861.801.80typical

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.

61.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 40 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

61.6%U.S. median 51.5%
Got home and stayed home
10.5%U.S. median 10.7%
Went back to hospital
0.41U.S. median 0.31
Therapy hours / resident / day
0.19hours / resident / day
Physical therapy
0.21hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.41 therapist hours per resident per day in 2026Q1 — more than 70% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF61.6%CMS range 46.8–75.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.5%CMS range 7.0–16.410.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot 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 dischargenot 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 dischargenot 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 identifiednot 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 settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot 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 worsenednot 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 hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.241.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.89
RN hours/ resident / day
0.56
LPN hours/ resident / day
1.99
Aide hours/ resident / day
3.44
Total nurse hours/ resident / day
0.49
RN hoursweekends
58.1%
Total nursing turnover
27.3%
RN turnover

How full it usually is: this home is certified for 85 beds and averages 66.8 residents a day — about 79% occupied, or roughly 18 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 3.44 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.89 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.99 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 3.10 hrs/resident/day on weekends vs 3.57 on weekdays — 13% thinner on weekends. RN hours go from 1.05 to 0.49 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%. 3 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

Inspection trend

6
deficiencies at the latest standard inspection (2023-10-05)
8
at the previous standard inspection (2021-07-26)

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

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

Inspection deficiencies

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

ABCDEFGHIJKL

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

39 citations, most serious first. The 12 most serious are shown; the remaining 27 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2024-06-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interviews, review of a facility investigation, and review of facility policy, the facility failed to ensure staff provided adequate supervision and intervention to prevent Resident #01, who had impaired cognition, was at risk for elopement, was housed on a secured memory care unit and who had a history of eloping from his bedroom window, from leaving the facility unsupervised. This resulted in Immediate Jeopardy when one resident (#01) was placed at potential risk for serious life-threatening harm and/or injury when the resident was displaying a change of condition and was observed pacing near the nurse's station and the resident was noted to be observing Licensed Practical Nurse (LPN) #110 closely. Resident #01 eloped from his bedroom window without staff knowledge and was found 2.3 miles from the facility, leaving a Dollar General store in a very busy area of town. This affected one (#01) of six residents reviewed for risk for elopement. The facility census…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · Jcited before2023-11-21 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, observation, resident interview, staff interview, review of the facility's Self-Reported Incident (SRI) and investigation, review the National Weather Forecast, and review of facility policy, the facility failed to provide adequate supervision to ensure a cognitively impaired resident, assessed to be at moderate risk for elopement from the facility and had previous attempts to elope, did not elope from the facility. This resulted in Immediate Jeopardy when Resident #26 was placed at risk for potential serious harm and/or injury when the resident eloped from the facility without staff knowledge and exited through the front door. The resident was missing for approximately six hours before being found approximately 3.9 miles from the facility, after accepting a ride from a neighbor of the facility, riding public transportation, accessing funds from the bank, and…

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

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · E2025-11-20 · tag F0760 — failed to prevent significant medication errors — pattern
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff and resident interview and policy review, the facility failed to ensure they were free from significant medication errors when the nurse failed to administer medications according to the physician orders. This affected six (#39, #05, #49, #10, #40, #75) of seven residents reviewed for late medications. The census was 76. Findings include:1.Medical record review for Resident #75 revealed an admission date of 09/05/25. Medical diagnoses included acidosis, coronary artery disease, heart failure, and renal insufficiency. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #75 was cognitively intact. Review of the Medication Administration Audit Report dated 11/18/25 revealed the following medications were prescribed at 9:00 P.M., Pregabalin (anticonvulsant medication) capsule 25 milligrams (mg) to give one capsule two times a day, Atorvastatin (a cholesterol medication) Calcium Oral Tablet 40 mg to give one tablet at bedtime, Budesonide-Formoterol…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-11-20 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, interview, and policy review, the facility failed to ensure residents with enhanced barrier precautions (EBP) had clear signage or instruction indicating required personal protective equipment (PPE) and care activities that require what PPE. Additionally, the facility failed to ensure staff have awareness of the EBP policy. This affected 11 (#02, #05, #06, #10, #12, #19, #34, #36, #56, #68 and #73) of 11 residents reviewed for EBP. Additionally, the facility failed to clean and disinfect durable medical equipment (DME) between residents. This affected two residents (#14 and #78) of three reviewed. The facility also failed to ensure gloves were changed in between residents and hands were washed in-between resident care and after resident care. This affected one (#72) of three resident reviewed for incontinence care. The facility census was 76. Findings include:Based on medical record review, observation, staff interview, and policy review, the facility failed 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-20 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and staff interview, the facility failed to ensure timely incontinence care was provided. This affected one (#72) of three residents reviewed for incontinence. The census was 76. Findings include:Medical record review for Resident #72 revealed an admission date of 07/27/21. Medical diagnoses included disorganized schizophrenia, heart failure, Alzheimer's disease, and cerebrovascular accident. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #72 was severely cognitively impaired. Her functional status was set up or clean-up assistance with eating, dependent for toileting and transfers. She was substantial/maximal assistance for bed mobility. She was frequently incontinent for bladder and always incontinent for bowel. Observation of incontinence care for Resident #72 on 11/19/25 at 6:16 A.M. with Certified Nursing Assistant (CNA) #56 revealed the resident's brief was saturated and had leaked a small amount onto the incontinence pad she 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-20 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
    Make 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, review of the water temperature logs, and review of a plumbing invoice, the facility failed to ensure water temperatures were within normal limits. This affected one (#72) of three residents reviewed for water temperatures. The census was 76. Findings include:Medical record review for Resident #72 revealed an admission date of 07/27/21. Medical diagnoses included disorganized schizophrenia, heart failure, Alzheimer's disease, and cerebrovascular accident. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #72 was severely cognitively impaired. Her functional status was set up or clean-up assistance with eating, dependent for toileting and transfers. She was substantial/maximal assistance for bed mobility. She was frequently incontinent of bladder and always incontinent for bowel. Review of an invoice from a plumbing company dated 11/11/25 revealed the mixing valve from the hot water had to be replaced. Review of 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-06-20 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interview, and facility policy review, the facility failed to maintain a clean and sanitary kitchen. This had the potential to affect all 71 residents who reside at the facility. The facility census was 71. Findings include: An interview and observation during the initial tour of the kitchen on 06/11/24 at 10:26 A.M. with the Kitchen Supervisor (KS) #300 revealed the three compartment sink did not contain sanitizing solution to sanitize the dishes. KS #300 confirmed the facility has been out of sanitizer for the three compartment sink for several days. KS #300 confirmed the dirt, food debris, and black substance under [NAME] the three compartment sink and all along the walls throughout the kitchen and behind the equipment. KS #300 confirmed the cove base covering was tore off the wall under [NAME] the three compartment sink as well as a missing tile. KS #300 confirmed the trash cans in the kitchen have food debris and splattered substance running down the trash cans. KS #300…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-05 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record review, resident and staff interview, and policy review, the facility failed to ensure a call light was in place for a resident. This affected one (#68) of 24 residents reviewed for call light placement. The facility census was 76. Findings included: Medical record review for Resident #68 revealed an admission date of 03/26/23. Diagnoses included dementia, hypertension, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #68 was cognitively intact. Observations of the call light for Resident #68 on 10/03/23 at 9:14 A.M. and on 10/04/23 at 3:14 P.M. revealed the call light cord was hanging wrapped around the call light outlet and out of reach of the resident. At the time of the observations, Resident #68 said she didn't know where her call light was. Interview with State Tested Nursing Aide (STNA) #307 on 10/04/23 at 3:27 P.M. confirmed the call light wasn't within reach for Resident #68. Review of the policy titled Call…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-05 · tag F0645 — isolated
    PASARR 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 and staff interview, the facility failed to complete an accurate Pre-admission Screen and Resident Review (PASARR) for Resident #62. This affected one (Resident #62) of two residents reviewed for PASARR. The facility census was 76. Findings include: Review of Resident #62's medical record revealed an admission date of 03/14/23. Diagnoses included catatonic schizophrenia (diagnosis upon admission on [DATE]), major depressive disorder, psychosis, and dementia with behavioral disturbance. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 was moderately cognitively impaired. Review of Resident #62's PASARR dated 06/20/23 revealed the PASARR had only mood disorder marked as a serious mental disorder. The PASARR did not include Resident #62's diagnosis of catanoic schizophrenia, which Resident #62 had the diagnosis since admission on [DATE]. Interview with Certified Operations Specialist #249 on 10/03/23 at 3:35 P.M. verified Resident #62 had 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-05 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interview, and record review, the facility failed to allow the participation of the resident and/or resident representative in the comprehensive care plan when there was no evidence a care plan conference was conducted. This affected two (Resident #47 and #68) of two residents reviewed for care plan conferences. The facility census was 76. Findings include: 1. Record review for Resident #47 revealed an admission date of 11/05/22. Diagnoses included malignant neoplasm of larynx, chronic obstructive pulmonary disease, stenosis of larynx, acute tracheitis without obstruction, malignant neoplasm of laryngeal cartilage, shortness or breath, and chronic respiratory failure with hypoxia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 was cognitively intact. Further review of the medical record revealed there was no evidence of care planning conferences from 11/05/22 to 10/02/23. Interview with Resident #47 on 10/02/23 at 10:45 A.M. revealed he…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-05 · tag F0849 — isolated
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    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 hospice contract, the facility failed to ensure hospice services were provided and documentation of the services and care provided to a resident receiving hospice services were available at the facility. This affected one (Resident #15) of two residents reviewed for hospice services. The facility census was 76. Findings include: Review of the medical record for Resident #15 revealed an admission date of 08/11/22. Diagnoses included dementia, psychotic disturbances, and anxiety. Resident #15 was severely cognitively impaired and had been on hospice services since 04/19/22 for cerebral atherosclerosis. Review of Resident #15's hospice care binder visit notes from 08/10/23 to 10/05/23 revealed no documentation from nursing, home health aide, social worker, or chaplain that the visited Resident #15 and there was no documentation of the visit notes with the care and services provided to Resident #15. Review of Resident #15's Hospice Comprehensive Assessment and Plan of Care from 08/12/23 to 10/10/23 revealed Resident #15…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-05 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, record review, and policy review, the facility failed to follow appropriate infection control techniques when they failed to cleanse their hands after changing gloves and failed to appropriately clean a wound for Resident #64. This affected one (Resident #64) of three residents reviewed for skin conditions The facility census was 76. Findings include: Record review of Resident #64 revealed an admission date of 12/14/22. Diagnoses included rectal fistula, quadriplegia, pressure ulcer of sacral region stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed). Review of Resident #64's physician order dated 10/04/23 revealed an order for treatment to the coccyx wound to cleanse the area with wound cleanser, pat dry, apply collagen to wound base, pack with Dakin's soaked gauze, and cover with foam dressing every shift and as needed. Observation on 10/04/23 at 11:25 A.M. revealed Licensed Practical Nurse (LPN) #282 gathered supplies including collagen, wound cleanser,…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 27 citations
  • Potential for harm · Fcited before2023-08-18 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview with staff, the facility did not ensure food was prepared and served under sanitary conditions. This affected all the residents in the facility who consumed food from the kitchen except Resident # 61 who the facility identified as not eating by mouth. The facility census was 78. Findings include: Observation of the kitchen with Dietary Manager (DM)#109 on 08/18/23 at 10:25 A.M. revealed a large number of gnats and flies flying around the juice machine and the dishwasher. There was a moderate amount of mold/mildew on the heating and cooling vents in the ceiling above the dishwasher, on the wall to the left and above the dishwasher. There was a black, three-tiered cart between the bread storage racks which had a large stainless steel, steam table pan sitting on it with an unidentifiable orange liquid with meat and vegetables floating in it (looked like vegetable soup) and a cardboard box was inside the pan of this liquid which also had gnats flying all around it. There was an area above the steam table where the dry wall was falling down at 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-18 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor 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, review of the maintenance concern logs, interview with resident and interview with the staff, the facility failed to ensure the toilet in the bathroom of Resident #10 and #21 was in good working order. This affected two residents (Resident #10 and #21) of three reviewed for environment. The facility census was 78. Findings included: Review of the medical record for Resident #10 revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including depression, hypotension, osteoporosis, restless leg syndrome. insomnia, diabetes, and inflamed seborrheic keratosis. Review of the quarterly Minimum Data Set assessment for Resident #10, dated 07/17/23, revealed Resident #10 had moderately impaired cognition. Review of the medical record for Resident #21 revealed Resident #21 was admitted to the facility on [DATE] with diagnoses including acute kidney failure, hemiplegia to the right side, severe protein calorie malnutrition, dysphagia, chronic obstructive pulmonary disease,…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2021-07-26 · tag F0603 — failed to not confine residents against their will — pattern
    Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and staff interview, the facility failed to ensure residents were free from prolonged quarantine. This affected three (Residents #2, #7, and #18) of five residents in quarantine. The census was 54. Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 03/02/20 with diagnoses including chronic obstructive pulmonary disease, depression, and irritable bowel syndrome. Review of the quarterly minimum data set assessment dated [DATE] revealed Resident #2 had moderate cognitive impairment. Review of Resident #2's immunization records revealed Resident #2 received the first dose of the COVID-19 vaccine on 12/22/20 and received the second dose on 01/12/21. Review of the physician order dated 06/30/21 revealed Resident #2 was placed in droplet precautions and the droplet precautions were discontinued on 07/21/21. Review of the health status note dated 06/30/21 revealed Resident #2 complained of a dry cough. Review of the medical record 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-07-26 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure activities were completed as scheduled and met the needs of the residents. This affected three (Residents #10, #43 and #47) of 54 residents in the facility. The census was 54. Findings include: 1. Observation of Resident #10, Resident #43, and the memory care unit on 07/19/21 at 10:23 A.M. revealed Resident #10 was observed in his bed, Resident #43 was observed in her bed, and no structured activities were observed occurring in the memory care unit. Observation of Resident #10, Resident #43, and the memory care unit on 07/19/21 at 2:22 P.M. revealed Resident #10 was seated in the common area, Resident #43 was observed in her bed, and no structured activities were observed occurring in the memory care unit. 2. Review of the medical record for Resident #10 revealed an admission date of 04/06/21 with diagnoses including dementia, hypothyroidism, and schizoaffective disorder. Review of the admission minimum data set assessment dated…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-07-26 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to timely address a resident's pain. This affected one (Resident #203) of one resident reviewed for pain management. The census was 54. Findings include: Review of the medical record for Resident #203 revealed an admission date of 07/09/21 with diagnoses including congestive heart failure, cerebral infarction, and chronic obstructive pulmonary disease. Review of the admission minimum data set assessment dated [DATE] revealed Resident #203 had severe cognitive impairment. Review of the skilled nursing note dated 07/10/21 revealed Resident #203 reported a pain level of four out of ten and staff completed non-medication interventions for pain. Review of the health status note dated 07/10/21 at 8:58 A.M. revealed Resident #203 complained of pain and a new order was received for routine pain medication. Review of the nursing note dated 07/10/21 at 3:08 P.M. revealed Physician Assistant (PA) #1005 ordered Norco Tablet 5-325 milligram (mg), give one tablet by…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-07-26 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    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 attempt non-pharmacological interventions before administering an as needed anti-psychotic medication. This affected one (Resident #38) of five residents reviewed for unnecessary medications. The facility census was 54. Findings include: Review of the medical record revealed Resident #38 was admitted to the facility on [DATE] with a diagnoses including psychosis not due to a substance or know physiological condition, schizoaffective disorder, bipolar type, anemia in chronic kidney disease, vascular dementia with behavioral disturbance, suicidal ideations, major depressive and anxiety disorder. The Minimum Data Set (MDS) assessment, dated 05/03/21, revealed Resident #38 was cognitively impaired. Review of the physician orders dated 07/15/21 revealed Haloperidol (anti-psychotic/anti-manic) tablet, five milligrams (mg), give one tablet by mouth, every eight hours, as needed for agitation. Review of the Medication Administration Record (MAR) on…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-07-26 · tag F0770 — failed to provide lab services — isolated
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and staff interview, the facility failed to have labs drawn as ordered. This affected two (Residents #9 and #13) of five residents reviewed for unnecessary medications. The facility census was 54. Findings include: 1. Review of the medical record revealed Resident #9 had physician orders dated 05/17/20 to have a Digoxin level to be drawn every six months in April and October. Review of the lab work sheet revealed the Digoxin level was drawn on 07/16/21. Interview with the Director of Nursing (DON) on 07/22/21 at 3:00 P.M. revealed the lab was drawn in July instead of April as ordered. 2. Review of the medical record for Resident #13 revealed a physician order dated 05/19/21 for Lipid Panel, Hemoglobin A1C, thyroid stimulating hormone (TSH), comprehensive metabolic panel (CMP), Depakote every 6 months in February and August. Review of the lab documentation dated 05/12/21 revealed the Depakote level was drawn in May and should have been drawn in February. Interview with the DON on 07/22/21 at 4:00 P.M. confirmed the lab draw was three months late being drawn.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2019-03-28 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and policy review, the facility failed to have proper sanitizing of dishes, failed to ensure food was not out dated, and failed to maintain a clean environment in the kitchen. This had the potential to affect 64 residents who received meals from the kitchen; one resident received no food by mouth. The census was 65. Findings include: 1. During observation on 03/25/19 at 9:00 A.M., there was a large amount of a black substance on the ceiling of the dry storage room, back hallway and by the dishwasher. During interview on 03/25/19 at 9:00 A.M., Dietary Manager #145 stated they had a cleaning party a couple of days ago and they washed the walls. The facility has trouble with condensation from the dishwasher and they were getting a new dishwasher this week. During interview on 03/28/19 at 10:00 A.M., Maintenance Staff #161 verified there was a black substance on the walls and ceiling of the kitchen. He stated they had a fan on the roof that quit working that draws the moisture out and they did not know that it was not working. 2. During observation on…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2019-03-28 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review, interview and policy review, the facility failed to implement a Legionella water management program. This had the potential to affect all 65 residents. Finding include: Review of the document titled worksheet to identify buildings at increased risk for Legionella growth and spread, dated 03/24/19, revealed the facility needed a water management program. Interview with Regional Quality Assurance Manager on 03/28/19 at 3:15 P.M. verified that the water management program had not been implemented at this time. Review of facility policy titled Legionella Water Management Program, dated July 2017, revealed number five, letter b of the policy states that the will have a detailed description and diagram of the water system in the facility including the following 1). receiving, 2) cold water distribution, 3) heating, 4) hot water distribution, and 5) waste. Letter C states that the facility will identify areas in the mater system that could encourage the growth and spread of Legionella or other waterborne bacteria.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2019-03-28 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview the facility failed to serve residents at the same time at the same table. This affected two residents (#11 and #55) of 15 who were in the dining room. The facility census was 65. Findings include: Observation on 03/25/19 at 12:06 P.M., of the facilities main dining room revealed there were 15 residents seated in dining room and two staff passing out trays. There was one table with three residents (#10, #11, and #55) sitting at the same table. Resident #10 received her tray at start of service and Resident #11 and #55 who were seated with Resident #10 did not receive a tray. Staff continued to pass other trays out in the dining room randomly and not at same table. At 12:18 P.M., and Resident #11 and Resident #55 were still awaiting to be served. Resident #10 was almost finished eating. At 12:20 P.M., all residents were served in the dining room except Resident #11 and Resident #55. Interview on 03/25/19 at 12:20 P.M., with Resident #10 revealed the kitchen always got trays mixed up. Resident #11 and Resident #55 revealed they did not know why they…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2019-03-28 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop 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 ensure accurate comprehensive care plans were in place for three residents (#3, #11, and #57) of four reviewed for comprehensive care plans. The facility census was 65. Findings include: 1. Review of Resident #11's medical record revealed the resident returned from the hospital on [DATE] with diagnoses including heart failure, paranoid schizophrenia, and type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had severe cognitive impairment. Review of the March 2019 physician orders revealed the resident had an order for Eliquis (blood thinner) 5 milligrams (mg) one tablet twice a day. The order was initiated on 01/27/19. There was no evidence there was a care plan for the use of the anticoagulant. Interview with Regional Director of Operations #101 on 03/27/19 at 4:35 P.M., confirmed there was no care plan for the use of Eliquis and there should have been one. 2. Review of…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2019-03-28 · tag F0678 — failed to provide CPR when needed — pattern
    Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
    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 ensure advanced directives were completed and accurate. This affected four residents (#6, #11, #25, and #57) of six reviewed for advance directives. The facility census was 65. Findings include: 1. Review of Resident #6's medical record revealed an admission date of 01/28/19 with diagnoses including moderate protein-calorie malnutrition, chronic respiratory failure with hypoxia, and pleural effusion. Review of the resident's physician's orders revealed an order dated 02/07/19 revealed the resident's code status was CCA (comfort care arrest). Continued review of the resident's medical record revealed no evidence of a do not resuscitate (DNR) identification form signed by the resident and physician. Interview with Regional Director of Operations (RDO) #192 on 03/27/19 at 12:25 P.M. verified the resident did not have a DNR identification form on record. 2. Review of Resident #25's medical record revealed an admission date of 01/11/19 with diagnoses including spinal stenosis, atrial fibrillation, shortness 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2019-03-28 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to ensure residents had a physician order for the use of oxygen. This affected two (Resident #57 and Resident #364) of eight residents receiving oxygen therapy. The facility census was 65. Findings include: 1. Review of the medical record for Resident #57 revealed an admission date of 03/04/19 with diagnoses including chronic obstructive pulmonary disease (COPD). The resident had no physician order for oxygen and no care plan for the use of oxygen. Observation of Resident #57 on 03/25/19 at 11:53 A.M. and on 03/26/19 at 4:11 P.M. Resident #57 was receiving oxygen at three liters per minute via nasal cannula. During interview on 03/26/19 at 4:11 P.M., Registered Nurse (RN) #175 stated the resident was receiving oxygen. During interview on 03/27/19 at 9:29 A.M., RN #194 verified there was no physician order for the resident to receive oxygen. 2. Review of the medical record for Resident #364 revealed an admission date of 03/18/19 with diagnoses including COPD. The resident had no physician order for oxygen and no…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2019-03-28 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to follow the menu and serve all items listed; failed to follow the recipe for puree foods; failed to provide finger foods as ordered; and failed to meet residents nutritional needs. This affected 64 residents who receive food from the kitchen. The facility census was 65. Findings include: 1. During observation of the dining room and hall trays on 03/25/19 P.M. from 12:00 P.M. to 12:36 P.M., no dinner roll was served as listed on the menu. Review of facility menu for 03/25/19 included a dinner roll with the meal. During interview on 03/25/19 at 12:29 P.M., Dietary Manager #145 stated dinner rolls were not served because they did not look good and no substitution was served for the rolls. 2. During observation of puree food preparation on 03/25/19 at 4:20 P.M., Dietary [NAME] #171 placed two pieces of chicken in the food processor and added an unmeasured amount of water. He started the food processor and added an additional unmeasured amount of water. During interview at the time of the observation, Dietary [NAME]…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-03-28 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident and staff interview, the facility failed to ensure a resident received showers per his schedule and choice. This affected one resident (#9) of two residents reviewed for choices. The facility census was 64. Findings include: Review of Resident #9's medical record revealed an admission date of 04/12/16. Medical diagnoses included hemiplegia and hemiparesis following cerebrovascular disease, Parkinson's disease, chronic obstructive pulmonary disorder, and heart failure. Review of Resident #9's care plan revised on 05/14/18 revealed he required assistance with activities of daily living due to weakness, cerebrovascular accident with left hemiparesis, chronic obstructive pulmonary disease, difficulty with balance, unsteady gait, impulsivity, and needing encouragement to bathe and complete personal hygiene. Interventions included providing extensive assistance with one staff member for bathing, showering, and personal hygiene on Tuesdays and Fridays 7:00 A.M. through 7:00 P.M.…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-03-28 · tag F0623 — isolated
    Provide 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 medical record review and staff interview, the facility failed to notify the resident/resident representative in writing of the reason for a transfer to the hospital. This affected one (#11) of two residents reviewed for hospitalization. The facility census was 65. Findings include: Review of Resident #11's medical diagnoses revealed the following diagnoses; heart failure, sepsis, and paranoid schizophrenia. The resident was hospitalized on [DATE] and returned on 01/15/19. Resident #11 was then hospitalized from [DATE] until 01/26/19. Review of the comprehensive assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of Resident #11's progress notes dated 01/05/19 at 4:15 A.M., revealed the resident was noted to have labored breathing and vitals were taken. Emergency services (EMS) was notified to transport the resident to the hospital. The resident was her own person and the contact person listed for emergency was unable to be contacted. The Director of Nursing (DON) of…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-03-28 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and facility policy review, the facility failed to ensure residents had baseline care plans in place. This affected three residents (#6, #57, and #364) of eight residents who were new admissions. The facility census was 65. Findings include: 1. Review of the medical record for Resident #57 revealed an admission date of 03/04/19 with diagnoses including. anxiety, depression, chronic obstructive pulmonary disease (COPD), and delusional psychosis. The resident was noted to be on oxygen at two liters. There was no evidence there were any baseline care plans developed. Review of the admission minimum data set (MDS) assessment dated [DATE] revealed Resident #57 had cognitive deficits, displayed no behaviors, received antipsychotic medication and antidepressant medications, and received oxygen therapy. His comprehensive care plan decision date on the MDS was 03/13/19. Review of physician orders dated March 2019 revealed Resident #57 had orders 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-03-28 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of a facility policy, the facility failed to ensure an interdisciplinary care conference was held for a resident. This affected one resident (#6) of one resident reviewed for care planning. In addition, the facility failed to ensure a resident's care plan was revised timely. This affected one resident (#21) of one resident reviewed for positioning/mobility. The facility census was 65. Findings include: 1. Review of Resident #6's medical record revealed an admission date of 01/28/19 with diagnoses including moderate protein-calorie malnutrition, dyspnea, irritable bowel syndrome, anxiety, chronic respiratory failure with hypoxia, and pleural effusion. Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no impairment in cognition. Interview with Resident #6 on 03/27/19 at 1:36 P.M., revealed she has not had a care conference. She was upset as she wanted to discuss plans for discharging to her home. Review of…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-03-28 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and policy review, the facility failed to assess residents for pain. This affected two (Residents #47 and #364 ) of three residents reviewed for pain . The facility census was 65. Findings include: 1. Review of the medical record for Resident #47 revealed a readmission date of 02/24/19 with diagnoses of traumatic brain injury and atrial fibrillation. Review of the quarterly comprehensive assessment dated [DATE] revealed Resident #47 had no cognitive deficits and experienced frequent pain. The medical record contained no documentation of a pain assessment. Review of the care plan for pain revealed the resident was at risk for pain and interventions included to monitor for pain and record pain scale, anatomical location, onset, duration, aggravating factors, and relieving factors. Review of physician orders dated March 2019 revealed to assess for pain every shift using the one to ten pain scale or facial expression pain scale and as needed and administer Hydrocodone three times 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-03-28 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure 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 — the official record, unedited, may be distressing

    Based on observation, interview, policy review, and pharmacy guidelines for medication storage, the facility failed to ensure insulin was properly labeled. This affected one (200 hall medication cart) of four medication storage areas. The facility census was 65. Findings include: Observation of the 200 hall medication cart on 03/27/19 at 4:30 P.M. revealed three insulin pens in use and not labeled with the first use date or expiration date. Interview with Licensed Practical Nurse #150 at the time of observation verified the insulin pens had been used and were not labeled or dated. Review of the facility policy titled Storage of Medications, revised April 2007, revealed the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Review of facility policy Medication Storage Guidelines, dated November 2018, revealed insulin pens were to be stored at room temperature for 28 days after opening.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-03-28 · tag F0770 — failed to provide lab services — isolated
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure a resident's laboratory test was completed as ordered. This affected one (Resident #6) of three residents reviewed for pain. The facility census was 65. Findings include: Review of Resident #6's medical record revealed an admission date of 01/28/19. The physician had a physician's order dated 03/21/19 to obtain a serum creatinine level on 03/22/19. There was no evidence in the medical record the serum creatinine level was completed. During interview on 03/27/19 at 11:25 A.M., Regional Quality Assurance Manager #194 verified the facility did not obtain the resident's serum creatinine level ordered 03/21/19.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-03-28 · tag F0926 — failed to keep the home smoke-free / fire-safe — isolated
    Have policies on smoking.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and policy review, the facility failed to provide a clean and well maintained resident smoking area that was free from used smoking materials. This affected 12 ( Resident #2, #5, #6, #9, #12, #20, #34, #47, #54, #58, #364, and #369 ) residents in the facility that are current smokers. The facility census was 65. Findings include: During observation of the facility smoking area on 03/25/19 at 4:00 P.M., two plastic flower pots and one ceramic flower pot contained multiple cigarette butts. These flower pots were located next to facility entrance and approximately 15 feet from the smoking area. During interview on 03/25/19 at 4:15 P.M., Licensed Practical Nurse (LPN) #141 verified there was multiple cigarette buts in the three flower pots and stated they should not be there, that there was a trash can for the butts. She stated they must have done it over the weekend. LPN #141 asked Resident #47 at the time of the interview about the cigarette buts in flower pots. The resident stated they put them there at night time because that is where they smoke due…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2023-10-05 · tag F0625 — pattern
    Notify 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 medical record review, resident and staff interviews, resident representative interview, and facility policy review, the facility failed to notify the resident and/or resident representative of the bed hold policy upon the residents' discharge to the hospital. This affected four (Residents #16, #18, #69, and #76) of four residents reviewed for bed hold notification. The facility census was 76. Findings include: 1. Review of Resident #16's medical record revealed Resident #16 was admitted to the facility on [DATE]. Diagnoses included non-alcoholic steatohepatitis, irritable bowel syndrome without diarrhea, pancytopenia, sepsis, hepatic encephalopathy, cirrhosis of liver, chronic kidney disease, and acute kidney failure. Review of the medical record revealed Resident #16 was discharged to the hospital on [DATE]. There was no evidence in the medical record that Resident #16 and/or resident representative was provided a bed hold notice upon Resident #16's discharge to the hospital on [DATE] from 08/26/23 to…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2021-07-26 · tag F0574 — widespread
    The resident has the right to receive notices in a format and a language he or she understands.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to display the state survey agency information, including information on filing a complaint with the state survey agency in a conspicuous area that was readily available to residents and their representatives. The affected all 54 residents in the facility. Findings include: Observation on 07/19/21 at 8:00 A.M. on entrance to the facility, the state survey agency information and information on filing a complaint through the state agency was not observed in the lobby or common area. Further into the building, observation was made of multiple peg boards with various posted information. No mention of the state survey agency was posted on the information boards. Interviews and observations during Resident Council Meeting on 07/21/21 at 11:30 A.M. with Residents #30, #6, and Resident #7, all three residents confirmed they attend resident counsel meetings regularly. The residents revealed they were unaware of their right to file a complaint with the state survey agency. The residents did not know the state survey agency information…

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

    Resident Rights Deficiencies · Deficient, Provider has plan of correction
  • No harm found · C2021-07-26 · tag F0577 — widespread
    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, resident and staff interview and record review the facility failed to post the past survey results in a conspicuous area that was readily available to residents and their representatives. The affected all 54 residents in the facility. Findings include: Observation on 07/19/21 at 8:00 A.M. on entrance to the facility, the past survey results were not located in the lobby common area. Further into the building, observation was made of multiple peg boards with various posted information. No mention of the location of the past survey results were posted on the information boards. Interviews and observations during Resident Council Meeting on 07/21/21 at 11:30 A.M. with Residents #30, #6, and Resident #7, all three residents confirmed they attend resident council meetings regularly. Interview revealed the residents were unaware the past survey results were required to be available to them for review. The residents did not know the location of the past survey results. Observations on 07/21/21 at 11:40 A.M. of the common area lobby and common area information boards…

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

    Resident Rights Deficiencies · Deficient, Provider has plan of correction
  • No harm found · C2021-07-26 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview, the facility failed to update the daily posted staffing. The affected all 54 residents in the facility. Findings include: During observation on 07/19/21 at 8:00 A.M. on entrance to the facility, the posted nurse staffing on the wall near the front desk was dated for Friday 07/16/21. During interview on 07/19/21 at 8:10 A.M., Business Office Manager (BOM) #406 confirmed the daily posted nurse staffing information was dated for 07/16/21 and had not been updated since Friday morning. BOM #406 stated the nurse on duty on the weekends should update the posted staffing each day. The staffing policy was requested from the Administrator but was not provided for review at the time of exit.

    Nursing and Physician Services Deficiencies · Deficient, Provider has plan of correction
  • No harm found · C2019-03-28 · tag F0607 — failed to have anti-abuse policies — widespread
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on personnel file review and staff interview, the facility failed to conduct reference checks on six of six new employees, Registered Nurse (RN) #123, Licensed Practical Nurse (LPN) #141, State Tested Nursing Assistant (STNA) #135, #137, #130, and #188. This had the potential to affect all 65 residents of the facility. Findings include: 1. Review of RN #123's personnel file revealed a hire date of 06/01/18. There was no evidence reference checks were completed. 2. Review of LPN #141's personnel file revealed a hire date of 05/17/18. There was no evidence reference checks were completed. 3. Review of STNA #135's personnel file revealed a hire date of 04/12/18. There was no evidence reference checks were completed. 4. Review of STNA #137's personnel file revealed a hire date of 09/25/18. There was no evidence reference checks were completed. 5. Review of STNA #130's personnel file revealed a hire date of 03/06/19. There was no evidence reference checks were completed. 6. Review of STNA #188's personnel file revealed an hire date of 07/05/18. There was no evidence reference…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has plan of correction

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

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

Fines & penalties

$34,976 in federal fines across 2 penalties.

  • $19,383 — penalty dated 2024-06-20
  • $15,593 — penalty dated 2023-10-05

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 MICHAEL SLYK — 7 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 52.9-0.9 vs chain
Health inspection 2 of 53.0-1.0 vs chain
Staffing 1 of 51.3-0.3 vs chain
Quality measures 5 of 54.4+0.6 vs chain
The other 6 homes this chain runs (chain average 2.9★, 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 / managerTypeRoleShareSince
D'AMICO, DANIELIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; ADP OF THE SNF33%since 05/23/2018
SLYK, MICHAELIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER67%since 09/01/2022
MSTC DEVELOPMENT INCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/02/2025
RYDER, GWYNNIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/28/2025
DIXON, KOBYIndividualADP OF THE SNFsince 01/01/2025
FRANCIS, SHERRIIndividualADP OF THE SNFsince 05/01/2025

CMS files one row per role, so the 11 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$9.5M
Net patient revenuemost recent cost report
+0.4%
Operating marginrevenue minus expenses
$482K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 71%Medicare 8%Other / private 21%

About 71% 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 $482K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

$338per resident / day
operating cost
$10,284per month
≈ monthly operating cost
$340per day
avg. revenue, all payers

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

What families pay in OH

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 365684. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2023-10-05, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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