Carriage Inn Of Steubenville
3102 St Charles Drive, Steubenville, OH 43952 · For profit - Limited Liability company · 120 certified beds · (740) 264-7161 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- it has an abuse, neglect, or exploitation citation (F0602), cited Sep 2024
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — 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 (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 3 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 | 3.6% | 5.3% | 15.4% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 3.7% | 6.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.2% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.4% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 51.8% | 30.1% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.7% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 2.8% | 6.1% | 16.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 34.4% | 25.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.7% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 32.3% | 21.4% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 14.9% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.3% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 99.3% | 75.6% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 19.4% | 24.9% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 6.4% | 12.9% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.10 | 1.73 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.94 | 1.80 | 1.80 | typical |
‡ 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.
50.1% 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 177 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 64.0% 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 100 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 0.37 therapist hours per resident per day in 2026Q1 — more than 62% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 14% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 50.1%CMS range 42.0–56.0 | 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 | 12.6%CMS range 9.5–15.7 | 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 | 64.0% | 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 | 55.0% | 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 | 56.0% | 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 | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 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 | 0.0% | 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 | 12.2%CMS range 8.7–15.4 | 7.1% | Oct 2023–Sep 2024 | worse than U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.24 | 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 120 beds and averages 99.1 residents a day — about 83% occupied, or roughly 21 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 3.59 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.81 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.70 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 3.29 hrs/resident/day on weekends vs 3.71 on weekdays — 11% thinner on weekends. RN hours go from 0.89 to 0.63 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 38% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
27 citations, most serious first. The 11 most serious are shown; the remaining 16 are one tap away and print in full.
- Actual harm · Gcited before2025-10-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, manufacturer guideline review, facility policy review and interview, the facility failed to ensure Resident #7 was comprehensively assessed and appropriate interventions were in place to prevent a burn from a hot liquid. In addition, the facility failed to ensure care planned/physician ordered fall interventions were in place to decrease the resident's risk of falls. This affected one resident (#7) of four residents reviewed for accidents. The census was 78. Actual Harm occurred on 09/19/2025 when Resident #7, who had severe cognitive impairment, required staff assistance with activities of daily living and received occupational therapy for identified upper extremity weakness, sustained large second degree burns to her left thigh requiring pain medication and treatments to the areas after the resident was provided hot tea in a Styrofoam cup that spilled on her lap. Findings include: Resident #7 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes…
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 before2026-04-06 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, maintenance ticket reviews, and staff interviews the facility failed to maintain safe flooring when it did not repair an area of flooring that was uneven and cracked on the transition care unit (TCU) utilized by residents. This affected nine mobile residents (#1, #9, #13, #25, #34, #42, #62, #95, and #105) of 20 residents residing on TCU. The facility census was 95.Findings include:Observation on 03/30/26 at 7:35 AM during the initial tour of the transition care unit (TCU) in front of the nurses' station door revealed a dip in the flooring and a piece of the flooring cracked with a hole starting. This was verified by certified nursing assistant (CNA) #481 who reported she would fill out a ticket to let the maintenance department know of concern. CNA #481 confirmed that the dip in the floor and crack have been there for a while. Observation and interview on 04/02/26 at 9:32 A.M. during a return tour of the TCU in front of the nurses' station door revealed a dip in the flooring and a piece of the flooring cracked with a hole starting. This was verified again 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.
- Potential for harm · D2026-04-06 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview and observation, and staff interview the facility failed to ensure a call light was accessible and within reach to meet resident needs. This affected one resident (#95) of 20 residents residing on the transitional care unit. The facility census was 95.Findings include:Review of the medical record for Resident #95 revealed admission to the facility on [DATE] with diagnoses including sepsis (a whole-body infection), venous ulcers to bilateral lower legs, severe peripheral vascular disease (narrowing of the vessels in the arms and legs decreasing blood circulation), diabetes, heart failure, heart disease, and acute kidney failure. Further review of the medical record for Resident #95 revealed a minimum data set (MDS) comprehensive assessment was completed on 03/25/26 and revealed Resident #95 required supervision and hands on assistance with dressing lower body, supervision with transfers from bed to wheelchair, and was dependent on staff for mobility of his…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-06 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
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, policy review, and interview, the facility failed to ensure an appropriate diagnosis was indicated for the use of an antipsychotic medication. This affected one resident (#2) of five residents reviewed for unnecessary medications. Findings include: Medical record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, non-Alzheimer's disease, unspecified fracture of right lower leg, osteomyelitis of right ankle and foot, diabetes mellitus, cirrhosis of liver, chronic obstructive pulmonary disease, and muscle wasting. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 10/01/25, revealed Resident #2 had severe cognitive impairment, a diagnosis of non-Alzheimer's dementia, and received an antipsychotic medication. Review of the physician order, dated 10/02/25, revealed the order for Risperdal (antipsychotic medication) oral tablet 0.5 milligrams (mg) one tablet by mouth two times a day for agitation. Review of the Monthly…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-06 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of medical records and facility policy, observation of medication administration, and staff interviews the facility failed to properly administer medications through a feeding tube for Resident #8. This affected one resident (#8) of one resident reviewed for tube feeding management and care. The facility census was 95.Findings include:Review of the medical record for Resident #8 revealed admission to the facility on [DATE] with diagnoses including high blood pressure, paraplegia (unable to use lower legs), aphasia (inability to speak), seizure disorder, depression, gastrotomy tube (for tube feeding and medications), and anoxic brain damage (lack of oxygen to brain leading to death of brain cells). Further review of the medical record for Resident #8 revealed a quarterly assessment of the minimum data set (MDS) completed on 02/13/26. The MDS revealed Resident #8 was unable to speak and communicate needs, was dependent for all cares and mobility, and was unable to complete an evaluation for mental…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-06 · tag F0697 — failed to manage pain — isolatedProvide 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 observation, record review, facility policy review and interview, the facility failed to provide effective and timely pain control for Resident #104 upon admission. This affected one resident (#104) of one resident who was reviewed for pain management. The facility census was 95.Findings include: Review of the medical record for Resident #104 revealed admission to the facility on [DATE] with diagnoses including heart disease with a triple vessel cardiac bypass, anemia (low blood count), depression, high blood pressure, spinal stenosis (narrowing of the vertebrae) of the neck and mid back, bilateral hip replacements, left knee replacement, and uterine cancer with radiation.Review of the hospital active medication list sent on 03/26/26 to the facility revealed Resident #104 was actively prescribed the following medication during hospitalization: Oxycodone (a potent opioid medication used to treat moderate to severe pain) five (5) milligrams (mg) every four hours as needed for post op(erative) pain,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-06 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review the facility failed to ensure safe storage of medication when medications were left on the breakfast tray for Resident #95. This affected one resident (#95) of twenty residents receiving medication on the transitional care unit. The facility census was 95. Findings include:Review of the medical record for Resident #95 revealed admission to the facility on [DATE] with diagnoses including sepsis (a whole-body infection), venous ulcers to bilateral lower legs, severe peripheral vascular disease (narrowing of the vessels in the arms and legs decreasing blood circulation), diabetes, heart failure, heart disease, and acute kidney failure. Further review of the medical record for Resident #95 revealed a minimum data set (MDS) comprehensive assessment was completed on 03/25/26 and revealed Resident #95 required supervision and hands on assistance with dressing lower body, supervision with transfers from bed to wheelchair, and was dependent on staff 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 · E2026-02-27 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review and review of facility policy the facility failed to ensure the lunch menu and spreadsheets were followed as written. This affected 13 residents (#1, #5, #9, #10, #17, #33, #40, #59, #68, #73, #86, #98 and #100) of 88 residents receiving meals from the kitchen. The facility identified one resident (#83) who did not eat by mouth (NPO). The facility census was 102. Findings include:1a. Review of the medical record for Resident #9 revealed an admission date of 11/12/18. Pertinent diagnoses included morbid (severe) obesity, type two diabetes mellitus, major depressive disorder. The physician had ordered on 01/16/24 for the resident to receive a reduced concentrated sweets (RCS), regular texture with regular/thin liquids with additional instructions to give fruit for dessert, skim milk per menu, and no bread at lunch and dinner unless a sandwich per menu or requested.Further review of Resident #9's medical record revealed a quarterly Minimum Data Set (MDS) assessment, dated 01/09/26, which indicated the resident was cognitively intact,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-10-23 · tag F0807 — failed to offer suitable drinks — isolatedEnsure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
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 a resident at risk for dehydration had water maintained at her bedside. This affected one (Resident #7) of three residents reviewed for dehydration. Findings include: Review of Resident #7's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease with a late onset, unspecified dementia, adult onset diabetes mellitus, personal history of malignant neoplasm of the pancreas, malignant neoplasm of an unspecified part of an unspecified bronchus/ lung with metastasis to the brain, chronic kidney disease, unsteadiness on feet, and a history of falls. Review of Resident #7's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and her cognition was severely impaired. She was not indicated to have displayed any behaviors and was not known to reject care. She required a partial to moderate assist with transfers 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.
- Potential for harm · Dcited before2025-10-23 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
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 ensure an effective antibiotic stewardship program was implemented, when a resident returned from the hospital on an antibiotic for the treatment of a urinary tract infection, and the facility's infection preventionist failed to ensure an appropriate antibiotic was ordered to adequately treat the infection. This affected one (Resident #7) of three resident's reviewed. Findings include: Review of Resident #7's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease with late onset, unspecified dementia, and chronic kidney disease. Review of Resident #7's nurses' progress notes revealed the resident was sent to the emergency room (ER) on 08/26/25 at 5:00 P.M. for complaints of chest pain. She complained of mid-sternum burning and heaviness. She returned to the facility on [DATE] at 1:40 A.M. with the diagnoses of a urinary tract infection (UTI). She returned to the facility with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-10-23 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and review of maintenance work orders the facility failed to maintain a safe and comfortable home like environment. This had the potential to affect one (Resident #07) of five residents rooms observed. the census was 78. Observation on 10/15/25 at 10:02 A.M. revealed a hole in the wall behind the head of Resident #7's bed. The hole was observed to be located behind the head of the resident's bed, near the baseboard. The hole was approximately eight inches by eight inches.Review of facility maintenance work orders for the past six months revealed no documentation of an order to repair the hole in the wall of Resident #7's room.Interview on 10/15/25 at 10:48 A.M. with Certified Nurses Assistant (CNA) #42 and Licensed Practical Nurse (LPN) #18 confirmed there was a larger hole in the wall of Resident #7's room. The hole was located behind the head board near the bottom of the wall. CNA #42 and LPN #18 stated they had not noticed the hole in the wall prior to it being pointed out. This deficiency demonstrates non-compliance investigated under Complaint…
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 16 citations
- Potential for harm · Dcited before2024-12-18 · 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 observation, medical record review, and interview, the facility failed to notify hospice of a resident refusal of respiratory treatments. This affected one (#83) of three residents sampled. The census was 84. Findings include: Medical record review revealed Resident #83 was admitted to the facility on [DATE] with diagnosis including Parkinson's disease. Review of the significant change Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #83 was severely impaired for daily decision-making, was receiving hospice services and had two or more falls resulting in no injuries and two or more falls resulting in injuries. Review of the electronic Physician Orders dated 07/11/24 revealed Continuous Positive Airway Pressure (CPAP) machine (a treatment for sleep apnea that involves wearing a mask while you sleep that delivers mild air pressure to keep breathing airways open during sleep) to be worn at bedtime and continue home settings. Review of the hospice Physician Plan of Care dated 10/16/24 revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, policy review and interview, the facility failed to ensure fall interventions were implemented. This affected one (#83) of three residents sampled. The census was 84. Findings include: Medical record review revealed Resident #83 was admitted on [DATE] with diagnosis including Parkinson's disease. Review of the significant change Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #83 was severely impaired for daily decision-making, was receiving hospice services and had two or more falls resulting in no injuries and two or more falls resulting in injuries. Review of the care plan: Potential for Falls: Resident is at risk for falls and fall related injury related to impaired vision, medication use, requires assist with transfers, and history of falls revised 10/30/24 revealed interventions including to keep call light within reach, assist with wearing proper footwear, assist with wearing glasses and encourage him to wear non-skid gripper socks when 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 · D2024-12-18 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, policy review and interview, the facility failed to provide appropriate care for oxygen and respiratory equipment. This affected one (#83) of three residents sampled. The census was 84. Findings include: Medical record review revealed Resident #83 was admitted on [DATE] with diagnoses including Parkinson's disease, generalized anxiety disorder, pneumonia and acute respiratory failure with hypoxia. Review of the electronic Physician Orders dated 07/11/24 revealed Continuous Positive Airway Pressure (CPAP) machine (a treatment for sleep apnea that involves wearing a mask while you sleep that delivers mild air pressure to keep breathing airways open during sleep) to be worn at bedtime and continue home settings. Review of the hospice Physician Plan of Care dated 10/16/24 revealed physician orders including to start oxygen via nasal cannula two liters to five liters per minute continuously. Review of the significant change Minimum Data Set 3.0 assessment dated [DATE]…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-18 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, policy review and interview, the facility failed to administer medications as ordered. This affected two (#50 and #58) of four residents observed for medication administration during 29 opportunities for error resulting in a 13.7% medication error rate. The census was 84. Findings include: 1. Medical record review revealed Resident #50 was admitted on [DATE] with diagnoses including hypertension, congestive heart failure, coronary artery disease and anxiety. Review of the electronic Physician Orders dated December 2024 revealed to administer medications including a chewable aspirin (ASA) 81 milligrams (mg), Isosorbide Dinitrate 30 mg once a day with physician parameters to hold if her systolic blood pressure (SBP) was less than 100, and Lopressor 25 mg with physician parameters to hold if her SBP was less than 100. On 12/17/24 between 9:39 A.M. and 9:48 A.M., observation of Resident #50's medication administration revealed Registered Nurse (RN) #209 assessed 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 · D2024-12-18 · 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 medical record review and interview, the facility failed to maintain a complete medical record. This affected one (Resident #85) of three residents sampled. The census was 84. Findings include: Closed medical record review revealed Resident #85 was admitted on [DATE] and discharged on 10/31/24. Review of the closed record revealed a handwritten Physician's Progress Notes dated 10/25/24 by Nurse Practitioner #210 and Physician's Progress note dated 10/31/24 by Physician #201. The progress note sheet was not labeled with a resident name, identification number or room number. There was no identifying information on the Physician's Progress Note sheet to indicate who the note was for. On 12/18/24 at 2:30 P.M., interview with the Director of Nursing (DON) verified the Physician Progress Note was in the closed record for Resident #85; however, with no resident information he could not verify what resident it was for without the physician and nurse practitioner to verify. The DON verified the medical record…
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 · E2024-09-23 · tag F0602 — failed to protect residents from theft of their belongings — patternProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of a facility self-reported incident (SRI), review of the facility investigation, facility policy review, and interview, the facility failed to ensure residents were free from misappropriation of medications. This affected 13 (Resident #1, #3, #4, #8, #12, #15, #16, #17, #18, #19, #20, #21, and #22) of 13 residents reviewed for misappropriation. The facility census was 99. Findings include: Review of the Self-Reported Incident (SRI) Tracking Number 251396, dated 08/31/24, revealed on 08/31/24, a concern was reported related to missing medications from Licensed Practical Nurse (LPN) #400's medication cart. On 08/31/24 at approximately 1:00 P.M. the Administrator was watching video cameras and noticed suspicious activity by LPN #400 while she was administering medications. LPN #400 was observed going through the narcotics drawer but not having the medication administration record (MAR) pulled up or documenting on the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-03-13 · 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 medical record review, interview, observation, and policy review the facility failed to trend and identify infections/organism. The facility also failed to use proper hand hygiene and glove use during suprapubic catheter care. This had the potential to affect all 102 residents residing in the building for infections and one resident (#78) of one observed for catheter care. Findings include: 1. Review of the infection control logs, and facility floor plans dated 10/2023 to 03/2024 revealed no evidence the facility was trending and identifying all infections/organism. The facility was utilizing floor plans to trend the infection. The October 2023 floor plan revealed the facility was trending genito- urinary (GU), gastro-intestinal (GI), skin, respiratory, eye, and others. Review of the October 2023 infection control log revealed there was two sepsis, one otitis media, one tonsillitis, three conjunctivitis, two clostridium difficile (C-diff), one methicillin resistant staphylococcus aureus (MRSA) one Vancomycin Resistant Enterococcus (VRE), four pneumonia, two cellulitis, two…
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 before2024-03-13 · 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 observation, interview, record review, and review of the facility policy the facility failed to ensure Resident's #8, #43, and #197's insulin pens had a date they were first opened and used recorded on the pen. This affected three residents (Resident's #8, #43 and #197) who received insulin and resided on the second floor nursing unit. Findings include: 1. Review of Resident #8's medical record revealed an admission date of 05/15/23 and diagnoses included chronic obstructive pulmonary disease, type two diabetes mellitus without complications and anxiety disorder. Review of Resident #8's physician orders dated 11/16/23 revealed Novolin 70/30 FlexPen subcutaneous suspension pen-injector (70-30) 100 units per milliliter (ml) (insulin NPH isophane and regular (human), inject 50 units subcutaneously one time a day for diabetes. 2. Review of Resident #43's medical record revealed an admission date of 05/10/23 and diagnoses included diabetes mellitus without complications, Parkinson's disease and dysphagia. Review of Resident #43's physician orders 07/06/23 revealed Levemir…
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 before2024-03-13 · tag F0881 — failed to use antibiotics responsibly — patternImplement a program that monitors antibiotic use.
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, interview, and policy review the facility failed to ensure residents met criteria for antibiotic treatment. This affected four residents (#29, #30, #78, and #82) of five reviewed for infections. Findings include: 1. Record review revealed Resident #82 was admitted to the facility on [DATE] with diagnoses including pulmonary fibrosis, heart disease, and history of urinary tract infection (UTI). Review of Resident #82's nursing note dated 03/04/24 revealed the resident had complaints of dysuria. New order from physician for Macrobid 100 milligram (mg) twice daily for five days and Pyridium 100 mg three times a day for four days. Review of Resident #82's infection screening evaluation note dated 03/04/24 revealed the resident did not have an indwelling catheter and was afebrile. She had acute dysuria, and no other symptoms were noted. Review of Resident #82's infection note dated 03/05/24 revealed the resident had possible UTI. No diagnostic test was performed, and the resident 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 · D2024-03-13 · 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 record review, staff interview and policy review, the facility failed to ensure accurate advanced directive information was present throughout the medical record. This affected three residents (#6, #28 and #32) of four residents reviewed for advanced directives. The facility census was 102. Findings Include: 1. Review of medical record revealed Resident #28 was admitted to the facility on [DATE]. Medical diagnoses included chronic obstructive pulmonary disease, unspecified asthma, respiratory failure, transient cerebral ischemic attack, abdominal aortic aneurysm, and heart failure. Review of Resident #28's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #28 was cognitively intact. Review of Resident #28's physician order, dated 08/15/23 identified Resident #28 was a Do Not Resuscitate Comfort Care (DNR-CC). Review of Resident #28's plan of care, dated 12/23/22 revealed Resident and Responsible Party had elected a DNR-CC code status. Review of Resident #28's paper medical…
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 before2024-03-13 · 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 record review, observation, review of an owner's manual/ technical specifications for a bed used for a resident, resident interview and staff interview, the facility failed to ensure a resident had an appropriate sized bed/ mattress to allow for proper positioning to accommodate his height and failed to identify and timely treat another resident who displayed signs of intense itching. This affected one (#65) of two residents reviewed for positioning and one (#198) of one resident reviewed for non-pressure skin conditions. Findings include: 1. A review of Resident #65's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included morbid obesity, a stage IV pressure ulcer to the right heel (full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer), and multiple contractures of the bilateral knees/ left hip/ left ankle. A review of Resident #65's quarterly Minimum Data Set (MDS) 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.
- Potential for harm · E2022-05-19 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and facility policy review the facility failed to monitor refrigerator temperatures on one of three resident units and failed to ensure refrigerators were maintained in a clean manner to prevent contamination and/or food borne illness. This had the potential to affect 19 residents (#33, #41, #49, #59, #76, #81, #82, #83, #84, #85, #86, #87, #88, #89, #90, #91, #233, #234 and #235) who resided on the Transitional Care unit (TCU) of 85 residents residing in the facility. Findings include: On 05/16/22 at 5:50 P.M. interview with Licensed Practical Nurse (LPN) #514 revealed if food was provided for residents on the Transitional Care unit (TCU) and the resident did not have their own refrigerator, the food was placed in the refrigerator in the Occupational Therapy (OT) room. On 05/16/22 at 5:50 P.M. observation of the refrigerator in the OT room revealed the thermometer in the refrigerator read 73 degrees Fahrenheit. Among the items stored in the refrigerator were two containers of cream cheese with no name noted. There were red and brown sticky substances…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-05-19 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility policy and procedure review and interview the facility failed to ensure Preadmission Screening and Resident Reviews (PASARR's) were completed accurately on admission and/or failed to ensure a new PASARR was completed following a change in diagnoses. This affected three residents (#12, #45, and #56) of five residents reviewed for PASARR. Findings include: 1. Record review revealed Resident #56 was admitted to the facility on [DATE] with diagnoses including anxiety and dementia with behavioral disturbance. Review of Resident #56's PASARR, dated 08/01/13 only included the determination that indicated the resident had no serious mental illness or a developmental disability. On 10/25/13 the resident was diagnosed with major depression disorder single episode and on 01/29/16 the diagnosis was changed to recurrent major depression disorder. On 07/08/18 psychosis not due to a substance or known psychological condition was added. The resident had an acute hospital stay and was readmitted…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-05-19 · tag F0661 — isolatedEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
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 closed record review, facility policy and procedure review and interview the facility failed to ensure the discharge summary completed for Resident #85 included a recapitulation of the resident's stay. This affected one resident (#85) of one resident reviewed for discharge. Findings include: Closed record review revealed Resident #85 was admitted to the facility on [DATE] and discharged to another skilled nursing facility on 03/11/22. The resident's diagnoses included severe protein malnutrition, osteomyelitis of vertebra, symbolic dysfunctions, dysphagia, weakness and need for assistance with personal care, pressure ulcer of sacral region, history of pulmonary embolism, encephalopathy, hyperlipidemia, gastrostomy, discitis and type II diabetes. A discharge note, dated 03/11/22 revealed follow up instruction education was provided to the transferring facility. The resident was made aware of transfer and signed discharge paper and verbalized understanding. Review of Resident #85's electronic medical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-05-19 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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 medical record review, facility policy and procedure review and interview the facility failed to ensure psychotropic medications were only administered when there were indications for use, failed to ensure non-pharmacological interventions were attempted prior to the administration of psychotropic medication ordered on an as necessary basis and/or failed to ensure orders for psychotropic medications were accurate and complete providing clear directions for use. This affected two residents (#8 and #48) of five residents reviewed for unnecessary medication use. Findings include: 1. Review of Resident #8's medical record revealed diagnoses including anxiety disorder and dementia with behavioral disturbance. Resident #8 had a physician's order for Ativan (anti-anxiety medication) 0.5 milligrams (mg) every four hours as necessary. Resident #8 also had an order for narcotic pain medication (Oxycodone HCL) 5 mg every four hours as needed for moderate to severe pain. Orders revealed staff were to monitor…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-05-19 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #2 was provided timely dental services to meet her needs. This affected one resident (#2) of three residents reviewed for dental care. Findings include: Review of Resident #2's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including cerebral palsy, type two diabetes, essential hypertension, hyperlipidemia and adult failure to thrive. Review of Resident #2's physician's orders revealed an order, dated 08/20/18 for dental consult as needed. The resident had an order, dated 08/23/18 for the use of a mechanical (Hoyer) lift for transfers. Review of Resident #2's care plans revealed the following: A plan of care (initiated 08/24/18) revealed a focus on alteration in mobility related to her using a wheelchair. The goal was for Resident #2 to participate with mobility by staff assisting her with transfers as needed, by providing a wheel chair as…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| BROWN & MURPHY HOLDING COMPANY INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 12/31/2004 |
| BERNSEN, KARA | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR | NO PERCENTAGE PROVIDED | since 12/03/2005 |
| BERNSEN, KENNETH | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR | NO PERCENTAGE PROVIDED | since 12/03/2005 |
| HUFF, JOSHUA | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR | NO PERCENTAGE PROVIDED | since 12/03/2005 |
| MANNING, SARAH | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR | NO PERCENTAGE PROVIDED | since 12/03/2005 |
CMS files one row per role, so the 10 rows in the source record cover these 5 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.
This home reported $1.7M paid to related parties — landlords or management companies under common ownership — equal to about 15% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OH
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Ohio Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 365271. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-06, 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 →
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