Otterbein St Marys Retirement Community
11230 State Route 364, St Marys, OH 45885 · For profit - Corporation · 53 certified beds · (419) 394-6330 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- lower-than-typical staff turnover (34% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its last standard health inspection was over 3 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 2.8% | 5.3% | 15.4% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 7.8% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.9% | 0.2% | 0.9% | typical |
| Long-stay residents with a urinary tract infection | 0.0% | 0.4% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 10.3% | 30.1% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.5% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 0.0% | 6.1% | 16.1% | check this* — see note marked star below the table |
| Long-stay residents on antianxiety or hypnotic medication | 38.5% | 25.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 92.3% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.2% | 3.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 17.6% | 21.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 8.5% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.4% | 1.2% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 85.6% | 75.6% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 23.2% | 24.9% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 10.7% | 12.9% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.58 | 1.73 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 2.29 | 1.80 | 1.80 | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
57.8% 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 157 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 51.9% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 81 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.49 therapist hours per resident per day in 2026Q1 — more than 80% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 57.8%CMS range 49.9–64.4 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.1%CMS range 7.6–13.7 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 51.9% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 49.4% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 35.8% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 79.5% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 97.8% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.8% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.7% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.7%CMS range 3.7–11.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.00 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 53 beds and averages 49.7 residents a day — about 94% occupied, or roughly 3 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.49 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.79 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.05 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 3.11 hrs/resident/day on weekends vs 3.65 on weekdays — 15% thinner on weekends. RN hours go from 0.94 to 0.40 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 34% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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 3 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.
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.
24 citations, most serious first. The 11 most serious are shown; the remaining 13 are one tap away and print in full.
- Actual harm · Gcited before2023-11-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, review of facility investigations, review of a Sheriff's Office incident report, review of the weather forecast, review of hospital discharge documents, and review of facility policy, the facility failed to prevent the elopement of confused residents from the secured memory care unit. This resulted in actual harm when one resident (#20) eloped from the facility without staff knowledge, was outside for approximately three hours in cool weather temperatures and light rain, was subsequently admitted to the hospital for evaluation and stabilization and was diagnosed with hypothermia (a significant and potentially dangerous drop in body temperature most commonly caused by prolonged exposure to cold) and a hypothermic blanket was applied. Furthermore, the resident was diagnosed with hypokalemia (low potassium) requiring intravenous (IV) fluids for hydration and found to have an episode of non-sustained ventricular tachycardia (heart arrythmia). Additionally, the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-04-03 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to provide wound care as ordered. This affected one (Resident #20) of three reviewed for wounds. The facility census was 47. Findings include: Review of the medical record for Resident #20 revealed an admission date of 01/25/24 with diagnoses including but not limited to displaced bimalleolar fracture (ankle) of right lower leg, fracture of upper end of right tibia (larger bone in lower leg, shinbone), type one diabetes, major depressive disorder, syncope and collapse, other specified disorders of bone density and structure to right thigh, and hypertension. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was cognitively intact. Resident #20 required extensive assistance for Activities of Daily Living (ADLs) and had surgical wounds. Review of the care plan dated 02/01/24 revealed Resident #20 had actual impairment to skin integrity of the right lower leg related to surgical wound. Interventions included but…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility policy, and staff interview the facility failed to ensure care was not delayed and a fall was properly assessed for one resident, Resident #1, out of three residents reviewed for falls. The current census is 46. Findings include: Record review of Resident #1 revealed the resident was admitted to the facility on [DATE] and discharged to another facility on 01/05/24. Diagnoses for Resident #1 included displaced fracture of the femur, chronic obstructive pulmonary disease, malnutrition, and heart disease. Review of Resident #1's Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition and was a fall risk. Review of Resident #1's care plans dated 12/2023 revealed a focus for falls. Interventions included non-skid footwear, keeping path free of clutter, and call light within reach at all times. Review of the fall assessment dated [DATE] at 1:30 P.M. revealed the nurse documented her progress note regarding the assessment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-14 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, review of facility investigations, and review of facility policy, the facility failed to report instances of potential neglect related to resident elopement to the state agency. This affected two (#20 and #21) of three residents reviewed for elopement. The facility census was 44. Findings Include: 1. Review of the medical record for Resident #20 revealed an admission date of 03/03/21. Diagnoses included major depressive disorder, schizoaffective disorder, dementia, Alzheimer's disease delusional disorder, and mood disorder. Resident #20 resided on the secured memory unit. Review of Resident #20's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of five, indicating Resident #20 was severely cognitively impaired. Resident #20 required supervision, set up only for her activities of daily living (ADLs). Resident #20 displayed verbal behavioral symptoms directed toward others one to three days during the review period.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-09-14 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and policy review, the facility failed to provide each resident or representatives with education regarding the risk and benefits of influenza immunization yearly when influenza vaccines were offered. This affected four (#2, #27, #31 and #36) out of five residents reviewed for immunizations. The facility census was 47. Findings include 1. Medical record review for Resident #2 revealed an admission date of major depressive disorder, syncope and collapse, cerebral infarction, poly osteoarthritis, vitamin D, hyperlipidemia, seasonal allergic rhinitis, chronic obstructive pulmonary disease (COPD), anemia, hypertension, chronic bronchitis, dementia without behaviors, chronic kidney disease stage three. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 revealed the resident had impaired cognition. Resident #2 required extensive assist for bed mobility, transfers, and toileting. Resident #13 required supervision for eating. Review of the Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-14 · tag F0655 — isolatedCreate 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
Based on medical record review, staff and resident representative interviews, and policy review, the facility failed to include resident representative in the development of a baseline care plan and failed to provide resident representative with a copy of the baseline care plan. This affected one (#198) out of five residents reviewed for baseline care plans. The facility census was 47. Findings include: Review of the medical record for Resident #198 revealed an admission date of 08/24/23 with medical diagnoses of sepsis, nondisplaced fracture of left humerus, hypothyroidism, and dementia. Review of the medical record for Resident #198 revealed an admission Minimum Data Set (MDS) assessment, dated 08/30/23, which indicated Resident #198 had severely impaired cognition and required extensive staff assistance with bed mobility, transfers, dressing, and toileting. Review of the medical record for Resident #198 revealed an admission Screen and Baseline Care plan assessment was completed by Director of Nursing (DON) on 08/24/23. Further review of the medical record revealed a signature…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-14 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff, physician and resident representative interviews, the facility failed to follow the physicians orders for treatment of a wound. This affected one (#8) of one reviewed for wound care. Additionally, the facility failed to provide care and services to treat a resident's constipation. This affected one (#198) out of one resident reviewed for constipation. The facility census was 47. Findings include: 1. Medical record review for Resident #8 revealed an admission on [DATE] with diagnoses including but not limited to myasthenia gravis with exacerbation, type two diabetes, sleep apnea, morbid obesity, major depressive disorder and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #8 revealed the resident had impaired cognition. Resident #8 required limited assistance from one staff member for bed mobility, transfers, and toileting. Resident #8 required application of non surgical dressing and ointments to areas other than feet. Review…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-14 · tag F0849 — isolatedArrange 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 and hospice staff interviews and review of a hospice contract, the facility failed to collaborate hospice services for the completion of a comprehensive plan of care for a resident admitted hospice services. This affected one (#13) of one reviewed for Hospice services. The facility census was 47. Findings include: Medical record review for Resident #13 revealed an admission dated on 12/09/22 with diagnoses including but not limited to sepsis, electrolyte imbalance, hypothyroidism, anemia, lymphedema, acute osteomyelitis, type two diabetes, obesity, seizures, obstructive sleep apnea, encephalopathy, intracranial abscess and granuloma. Review of the significant Minimum Data Set (MDS) assessment for Resident #13 dated 08/28/23 revealed the resident had intact cognition. Resident #13 required limited assist for bed mobility, extensive assist for transfers and toileting. Resident #13 required supervision for eating. Resident #13 was coded as receiving hospice care in the past 14 days. Review of the hospice plan of care dated 08/21/23 for Resident #13…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-06-10 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, resident and staff interview, review of the facility's shower schedules, shower/bath body audit sheets, and review of the state tested nurse aide (STNA) job summary, the facility failed to provide routine showers to a resident who was totally dependent on staff for bathing. This affected one (#15) of one resident reviewed for activities of daily living (ADLs). The facility census was 45. Findings include: Review of the medical record for Resident #15 revealed an admission date of 04/09/21 with diagnoses of fracture of the right fibula, chronic kidney disease, depression and heart failure. Review of the admission Minimum Data Set (MDS) assessment, dated 04/13/21, revealed Resident #15 was cognitively intact. She required extensive assistance to total assistance for activities of daily living (ADLs), including extensive assistance of two staff for dressing and personal hygiene. She was totally dependent on staff for bathing. Review of the plan of care revealed Resident #15 had an impaired ability to perform or complete activities of daily living for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-06-10 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, resident and staff interviews, and policy review, the facility failed to ensure non-pressure skin impairments were accurately assessed and routinely monitored. This affected one (#15) of two residents reviewed for non-pressure skin impairments. The facility census was 45. Findings include: Review of the medical record for Resident #15 revealed an admission date of 04/09/21 with diagnoses of fracture of the right fibula, chronic kidney disease, and heart failure. Review of the admission Minimum Data Set (MDS) assessment, dated 04/13/21, revealed surgical wounds were present upon admission for Resident #15. Review of the nurse progress notes from admission on [DATE] to 06/07/21 revealed no information about a new wound on her right leg at any time. Review of the physician orders, dated 04/09/21, revealed a dry dressing change to the right lower extremity daily. Skin checks to the right lower extremity every shift was ordered on 04/09/21. An immobilizer to the right…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-06-10 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, observation, staff interview and review of the facility's policy, the facility failed to accurately assess and routinely monitor residents with pressure ulcers. This affected two (#4 and #25) of three residents reviewed for pressure ulcers. The facility identified four residents with pressure ulcers. The facility census was 45. Findings include: 1. Review of the medical record for Resident #4 revealed an admission date of 03/05/21. Diagnoses included stage four pressure ulcer to sacral region (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed.), mononeuropathy, protein calorie nutrition, dementia with behavioral disturbance, muscle weakness, and colostomy. Review of Resident #4's plan of care, dated 03/10/21, revealed the pressure wound was to be assessed and monitored with length, width and depth when possible. The wound perimeter, wound bed and healing process was to be documented with improvements and declines in wound healing reported to the physician accordingly. Review…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 13 citations
- Potential for harm · D2021-06-10 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and facility policy review, the facility failed to have a diagnosis for the need of a catheter and failed to have physician orders for catheter care for a resident. This affected one (#93) of two residents reviewed for urinary catheters. The facility identified three residents with an indwelling catheter. The facility census was 45. Findings include: Review of the medical record for Resident #93 revealed she was admitted on [DATE] with diagnoses of acute respiratory failure, dysphagia, cardiomyopathy, pneumonia, diabetes mellitus and hypertension. Her admission Minimum Data Set (MDS) assessment was not yet completed. Review of the initial plan of care revealed a focus area for the use of a urinary catheter with goals and interventions for the use of the catheter. Further review of Resident #93's medical record revealed there was no diagnoses for the use of a catheter and no physician orders for the use and care of a urinary catheter. 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.
- Potential for harm · D2021-06-10 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview and facility policy review, the facility failed to ensure their medication error rate of less than five percent (%). There were 35 medication opportunities with 11 medication errors, resulting in a 31% significant medication error rate. This affected one (#94) of six residents observed for medication administration. The facility census was 45. Findings include: Review of the medical record for Resident #94 revealed she was admitted to the facility on [DATE] with diagnoses including cerebral infarction, atrial fibrillation, dysphagia and hemiparesis and hemiplegia. Review of the physician orders, dated 06/10/21, revealed medications including vitamin C (vitamin) 500 milligrams (mg.), Aspirin (anti-inflammatory and blood thinner) 81 mg, calcium citrate plus vitamin D (vitamin) 315 mg./200 units, cartia (treats high blood pressure) 120 mg., Geritol complete (vitamin) one tablet, Lutein (vitamin) 100 mg., Miralax (treats constipation) 17 grams, Clonidine…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-06-10 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, manufacturer's instructions and facility policy review, the facility failed to properly store medications. This affected one resident (#237) whose medications were found to be preset in one medication cart of two medication carts observed and one medication room of two medication rooms observed for medication storage. The facility had a total of three medication carts and two medication rooms. The facility census was 45. Findings include: 1. Observation on 06/07/21 at 8:07 A.M. on the North Hall at the nurse's station revealed a vial of Albuterol sulfate (bronchodilator) 3.0 milligrams (mg.) in 3.0 milliliters (ml.) was laying on the window ledge, unattended, not in a locked container or cart and not in any prescription package. The nurse was in a resident room. Interview with Licensed Practical Nurse (LPN) #49 on 06/07/21 at 8:12 A.M. verified the vial of Albuterol sulfate 3.0 mg. in 3.0 ml. was laying on the window ledge, unattended, not locked and not in any prescription package. LPN #49 stated she was not aware it was there and did not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2019-02-21 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of the facility's Legionnaires prevention documentation/policy and staff interview, the facility failed to develop and implement a legionella control plan with identified control measures. This had the potential to affect all 48 of 48 residents of the facility. The census was 48. Findings include: Review of a facility document titled Annual Legionnaires Policy Review dated 12/20/18 revealed quality assurance for water management would identify areas, control measures, who measures, and have documentation. Further review revealed this document did not identify control measures, frequency of control measure checks, who was responsible for completing checks, and what corrective action should be taken when control measures were out of desired ranges. Review of the facility's policy tilted Legionnaires Policy dated 09/06/17 revealed the facility will develop a water management program that would establish where control measures should be applied, how to monitor them, and establish ways how to intervene when control limits are not met. Further review revealed the policy…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2019-02-21 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medication storage area observations and staff interview, the facility failed to properly label and store medication. This affected two of four medications storage areas observed. The census was 48. Findings include: 1. Observation on 02/21/19 at 11:48 A.M., of the rehabilitation medication cart revealed an opened and undated bottle of the prescribed ophthalmic solution thera tears. Continued observation of the rehabilitation medication cart revealed an opened and undated foil package of prescribed ipratropium/albuterol inhalant solution. Interview on 02/21/19 at 11:50 A.M., with Registered Nurse (RN) #300 verified the bottle of prescribed thera tears and the foil package of prescribed ipratropium/albuterol inhalant solution located in the rehabilitation medication cart was opened and undated. RN #300 confirmed multi-dose medications should be labeled with the date the medication was opened. 2. Observation on 02/21/19 at 12:13 P.M., of the south hall medication revealed an opened and undated bottle of the supplement UTI Stat. Review of the supplement label revealed the open…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-02-21 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, resident and staff interviews, and review of a facility handbook, the facility failed to ensure a resident's dignity was maintained when a photograph was posted in the resident's room in view of other residents, staff and visitors. The picture was of the resident's legs and urinary catheter with a personal care directive hand written on the picture. This affected one (#25) of three residents reviewed for dignity. The facility census was 48. Findings include: Review of Resident #25's medical record revealed an admission date of 02/09/18. Medical diagnoses included spinal stenosis, generalized muscle weakness, paraplegia, altered mental status, neuromuscular dysfunction of bladder, fusion of lumbar spine, and hypertension. Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 15, indicating no cognitive impairment. The resident required extensive assistance with two plus staff members for bed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-02-21 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident record review and staff interview, the facility failed to ensure advanced directives stored in the hard chart and electronic health record (EHR) were consistent. This affected one (#11) of 16 resident records reviewed for consistency of advanced directives. The census was 48. Findings include: Review of the medical record for Resident #11 revealed the resident was admitted to the facility on [DATE]. Diagnoses include cerebral infarction, muscle weakness, dysphagia, thyroid disorder, major depressive disorder, osteoarthritis, hypercholesterolemia, gout, and disorder of the prostate. Review of Resident #11's hard chart revealed the outside binding of the resident chart was marked with the letter A. Continued review of the hard chart revealed the first page of the chart was the document DNR Identification Form dated 2015, the form identified Resident #11's code status was do not resuscitate (DNR) comfort care (CC) arrest (A). Review of Resident #11's EHR identified the resident's code status was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-02-21 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record reviews, resident and staff interviews, review of facility self-reported incidents (SRIs) and review of a facility policy, the facility failed to ensure their policy was implemented when potential resident to resident verbal abuse and potential misappropriation allegations were not reported to the Ohio Department of Health and were not investigated. This affected three (#17, #18 and #25) of three residents reviewed for abuse and misappropriation. The facility census was 48. Findings include: 1. Review of Resident #17's medical record revealed an admission date of 11/21/18. Medical diagnoses included nontraumatic intracerebral hemorrhage, generalized muscle weakness, difficulty walking, dysphagia, cognitive communication deficit, cerebral infarction, unspecified atrial fibrillation, atherosclerotic heart disease, ischemic cardiomyopathy, pulmonary hypertension, diabetes mellitus, and bipolar disorder. Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed a brief…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-02-21 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record reviews, resident and staff interviews, review of facility self-reported incidents (SRIs) and review of a facility policy, the facility failed to ensure potential resident to resident verbal abuse and potential misappropriation allegations were reported to the Ohio Department of Health and the Administrator. This affected three (Residents #17, #18 and #25) of three residents reviewed for abuse and misappropriation. The facility census was 48. Findings include: 1. Review of Resident #17's medical record revealed an admission date of 11/21/18. Medical diagnoses included nontraumatic intracerebral hemorrhage, generalized muscle weakness, difficulty walking, dysphagia, cognitive communication deficit, cerebral infarction, unspecified atrial fibrillation, atherosclerotic heart disease, ischemic cardiomyopathy, pulmonary hypertension, diabetes mellitus, and bipolar disorder. Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed a brief interview for mental status…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-02-21 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident and staff interviews, review of facility self-reported incidents (SRIs) and review of a facility policy, the facility failed to ensure potential resident to resident verbal abuse and potential misappropriation allegations were thoroughly investigated. This affected three (Residents #17, #18 and #25) of three residents reviewed for abuse and misappropriation. The facility census was 48. Findings include: 1. Review of Resident #17's medical record revealed an admission date of 11/21/18. Medical diagnoses included nontraumatic intracerebral hemorrhage, generalized muscle weakness, difficulty walking, dysphagia, cognitive communication deficit, cerebral infarction, unspecified atrial fibrillation, atherosclerotic heart disease, ischemic cardiomyopathy, pulmonary hypertension, diabetes mellitus, and bipolar disorder. Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 11, indicating moderate…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-02-21 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and resident and staff interview, the facility failed to ensure a dependent resident received bathing per his bathing schedule. This affected one (#17) of one residents reviewed for choices. The facility identified all 48 residents as requiring assistance for bathing. Findings include: Review of Resident #17's medical record revealed an admission date of 11/21/18. Medical diagnoses included nontraumatic intracerebral hemorrhage, generalized muscle weakness, difficulty walking, dysphagia, cognitive communication deficit, cerebral infarction, unspecified atrial fibrillation, atherosclerotic heart disease, ischemic cardiomyopathy, pulmonary hypertension, diabetes mellitus, and bipolar disorder. Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 11, indicating moderate impairment in cognition. The resident required extensive assistance with two plus staff for bed mobility, transfers,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-02-21 · tag F0770 — failed to provide lab services — isolatedProvide timely, quality laboratory services/tests to meet the needs of residents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review and staff interview, the facility failed to ensure a resident's laboratory tests were completed as ordered. This affected one (#17) of five residents reviewed for unnecessary medications. The facility census was 48. Findings include: Review of Resident #17's medical record revealed an admission date of 11/21/18. Medical diagnoses included nontraumatic intracerebral hemorrhage, generalized muscle weakness, difficulty walking, dysphagia, cognitive communication deficit, cerebral infarction, unspecified atrial fibrillation, atherosclerotic heart disease, ischemic cardiomyopathy, pulmonary hypertension, diabetes mellitus, and bipolar disorder. Review of the resident's physician's orders revealed an order written on 01/28/19 for a complete blood count (CBC) with differential, complete metabolic profile (CMP), and Depakote level in one week then repeat every four months. Review of the resident's laboratory work revealed he refused the CBC, CMP and Depakote level on 02/05/19. The laboratory paperwork indicated they would try to obtain specimens two more times…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-02-21 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident record review, staff and family interviews, the facility failed to ensure accurate documentation in the medical record for a physician ordered ankle foot orthotic (AFO). This affected one (#11) of one resident reviewed for contractures. The census was 48. Finding include: Review of the medical record for Resident #11 revealed the resident was admitted to the facility on [DATE]. Diagnoses include cerebral infarction, muscle weakness, dysphagia, thyroid disorder, major depressive disorder, osteoarthritis, hypercholesterolemia, gout, and disorder of the prostate. Review of Resident #11's physician order dated 05/25/17, revealed the resident was to have an AFO applied in the A.M. every day. The AFO was to be removed at bedtime. Review of Resident #11's treatment record (TAR) dated 02/19, revealed documentation the AFO was applied and removed per the physician orders. Multiple observations were made of Resident #11 throughout the day on 02/19/19 and 02/20/19 between 9:00 A.M. and 3:30…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to OTTERBEIN SENIORLIFE — 20 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 3.2 | +0.8 vs chain |
| Health inspection | 4 of 5 | 3.0 | +1.0 vs chain |
| Staffing | 3 of 5 | 3.2 | -0.2 vs chain |
| Quality measures | 4 of 5 | 4.1 | ≈ chain avg |
The other 19 homes this chain runs (chain average 3.2★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| OTTERBEIN LSC LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 01/01/2016 |
| OTTERBEIN HOME | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 100% | since 12/01/2021 |
| BORNS, DEBORAH | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 01/01/2017 |
| COFFIN, GORDON | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 01/01/2023 |
| DUES, STEVE | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 01/01/2013 |
| GAMBLE, CHARLES | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 07/01/2014 |
| IMWALLE, KAREN | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 01/01/2025 |
| INGRAHAM, JEFFREY | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 01/01/2024 |
| KROEGER, TYLER | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 01/01/2025 |
| STEINEMANN, JANE | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 12/01/2021 |
| VOISARD, DAVE | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 01/01/2021 |
| YOUNG, DANIEL | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 01/01/2025 |
| MEDAUGH, JOHN | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2020 |
| SLAVIK, BRUCE | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2017 |
| VONDERHAAR, STEVE | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2020 |
| GREEN, JAMES | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 11/21/2005 |
| WILSON, JILL | Individual | CORPORATE OFFICER | — | since 05/01/2009 |
| FUNCTIONAL PATHWAYS OF TENNESSEE LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/04/2025 |
| APP, LYNN | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2021 |
| BARTLETT, VICTORIA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2021 |
| BAYLIFF, BECKY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2021 |
| BROWNSON, WILLIAM | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2021 |
| BURKE, DANIEL | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2021 |
| COLEMAN, ROBERT | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2021 |
| FRALEY, RALPH | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2021 |
| GLOSSER, HEIDI | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2021 |
| HAWKINS, RITA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/16/2006 |
| HAZELBAKER, TOMAS | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2021 |
| HUNTER, RACHEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/01/2018 |
| SIBERT, TARA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/10/2024 |
| BAKER, STEVE | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 04/04/2025 |
| GALBUT, ABRAHAM | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 04/04/2025 |
| GALBUT, DANIEL | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 04/06/2025 |
| GALBUT, DAVID | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 04/04/2025 |
| GALBUT, ERIC | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 04/06/2025 |
| GALBUT, ROBERT | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 04/04/2025 |
| PARITZKY, JONATHAN | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 04/04/2025 |
| ROMBRO, DAVID | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 04/04/2025 |
| ZISEK, TODD | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 04/04/2025 |
| POLARIS PHARMACY SERVICES OF OHIO LLC | Organization | ADP OF THE SNF | — | since 12/01/2018 |
CMS files one row per role, so the 59 rows in the source record cover these 40 parties — each is shown once here with every role it holds. Nothing is omitted.
4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $343K 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
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OH
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Ohio Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 365953. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2023-09-14, 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.