Seasons Nursing And Rehab
456 Seasons Rd, Stow, OH 44224 · For profit - Corporation · 50 certified beds · (330) 688-5553 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- lower-than-typical staff turnover (28% vs 45% nationally) — better care continuity
- it has an abuse, neglect, or exploitation citation (F0606), cited May 2023
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (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
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
- 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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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 | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 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 | 3.2% | 5.3% | 15.4% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 6.8% | 6.2% | 5.4% | worse |
| 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 | 31.5% | 30.1% | 6.5% | typical for the 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 | 1.6% | 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 | 44.7% | 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 | 4.4% | 3.4% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 20.9% | 21.4% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 60.9% | 8.8% | 17.1% | check this† — see note marked dagger below the table |
* 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.
† This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.12 therapist hours per resident per day in 2026Q1 — more than 8% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 55% of this home’s weekday level — it runs therapy at close to weekday levels right through 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 | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 50 beds and averages 48.1 residents a day — about 96% occupied, or roughly 2 beds typically open. It runs essentially full — expect a waiting list. 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 3.18 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.41 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.79 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 2.72 hrs/resident/day on weekends vs 3.36 on weekdays — 19% thinner on weekends. RN hours go from 0.39 to 0.43 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 28% 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 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.
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.
27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.
- Potential for harm · F2025-03-03 · tag F0804 — failed to serve food at safe, palatable temperature — widespreadEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, resident and staff interview, taste of a test tray, and review of the facility policy, the facility failed to ensure meals were served at a palatable temperature. This affected nine residents (#3, #6, #12, #13, #23, #27, #33, #40, and #45) and had the potential to affect all 47 residents residing at the facility who receive food from the kitchen. Findings include: Interviews on 03/03/25 between 10:07 A.M. and 11:00 A.M. with Resident #3, #6, #12, #23, #40 and #45 revealed their food was not warm enough when served. Observation and interview on 03/03/25 at 12:11 P.M. of the food/tray service in the dining room revealed the steam table sat in the dining room in front of the kitchen entrance door. Dietary Manager #221 and Dietary Assistant #232 were plating the residents food from the steam table. The meal included meatball subs with mozzarella cheese, French fries and strawberries and bananas mixed with cottage cheese. There was no steam coming from the steam table and the plug to the steam table was lying on the floor and not plugged in. Dietary Manager #221…
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 · F2025-03-03 · tag F0908 — failed to keep essential equipment working — widespreadKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and resident and staff interview, the facility failed to ensure equipment used for storing and serving residents hot foods from was in good, working condition. This affected nine residents (#3, #6, #12, #13, #23, #27, #33, #40, and #45) and had the potential to affect all 47 residents residing at the facility who receive food from the kitchen. Findings include: Interview on 03/03/25 between 10:07 A.M. and 11:00 A.M. with Residents #3, #6, #12, #23, #40 and #45 stated their food was not warm enough when served. Observation and interview on 03/03/25 at 12:11 P.M. of the food/tray service in the dining room revealed the steam table sat in the dining room in front of the kitchen entrance door. Dietary Manager #221 and Dietary Assistant #232 were plating the residents' food from the steam table. There was no steam coming from the steam table and the plug to the steam table was lying on the floor and not plugged in. Dietary Manager #221 stated there was no outlet within reach that supported the cord. The steam table was purchased approximately six months ago, and 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 · Fcited before2025-03-03 · tag F0921 — failed to keep a safe, functional, sanitary building — widespreadMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, record review and review of the facility policy, the facility failed to ensure the resident's environment was maintained in a safe, sanitary. and comfortable environment. This affected one resident (#40) and had the potential to affect all 47 residents residing at the facility. Findings include: Record review for Resident #40 revealed an admission date of 03/02/21. Diagnoses included bipolar disorder, seizures, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 was cognitively intact. Observation on 03/03/25 at 10:24 A.M. of Resident #40's room revealed the walls had several deep gouges (make (a groove, hole, or indentation) with or as with a sharp tool or blade), in all of the walls. The walls were also dirty. There was a vent on the floor next to Resident #40's bed that was not secured to the floor and was approximately two to three inches shorter than the hole made for a floor vent. The bottom…
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 · F2023-05-24 · tag F0606 — failed to not employ staff found guilty of abuse — widespreadNot hire anyone with a finding of abuse, neglect, exploitation, or theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, policy review, and interview, the facility failed to ensure all staff were checked against the Nurse Aide Registry (NAR) prior to employment to ensure the employee did not have a finding entered into the State Nurse Aide Registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of property. This had the potential to affect all 50 residents in the facility. Findings include: Review of the Employee Changes form revealed the facility hired fifteen new employees from 05/23/22 to 05/23/23. Of those fifteen new employees, the facility did not check seven new employees against the nurse aide registry (NAR) for indications of abuse including Registered Nurse (RN) #820 hired 10/13/22; Licensed Practical Nurse (LPN) #822 hired 10/19/22; Dietary Aide #831 hired 11/01/22; RN #815 hired 12/05/22; RN #809 hired 02/03/23; RN #837 hired 03/08/23; and [NAME] #830 hired 04/05/23. Interview on 05/23/23 at 10:55 A.M. with Business Office Manager(BOM)/Human Resources (HR) #805 confirmed all new hires were not checked against the nurse aide…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-05-24 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interview and record review, the facility failed to ensure that leftovers and food out of its original container were labeled and dated properly. This had the potential to affect all 50 residents receiving food from the kitchen. Findings include: A tour of the kitchen on 05/21/23 from 8:00 A.M. through 8:20 A.M. with [NAME] #828 revealed the following was not labeled or dated in the walk-in refrigerator: one half wrapped watermelon, a pan of cooked cheeseburgers, an opened bag with wilted salad mix, and a pan of fruited gelatin. In the freezer there was chicken and corn wrapped with no label or date on the bags. [NAME] #828 verified the findings and stated that everything that was opened must be labeled and dated. Interview on 05/22/23 at 2:30 P.M. with Registered Dietitian (RD) #901 revealed she audits the kitchen monthly and her concerns that have been addressed was labeling and dating of food. Review of the updated facility policy titled; Date Marking revealed an established procedure for date marking shall be utilized by the facility. Two options for 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 · E2023-05-24 · tag F0550 — failed to protect resident dignity and rights — patternHonor 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 observations, interviews and record review, the facility failed to ensure residents were able to exercise their rights without coercion related to smoking. This affected four (Residents #12, #24, #30 and #34) of the 19 residents who smoked but had the potential to affect all residents (Residents #4, #6, #10, #11, #12, #19, #20, #21, #23, #24, #26, #28, #29, #30, #31, #34, #35, #38 and #43) who smoked. The facility census was 50. Findings include: 1. Review of the medical record revealed Resident #12 was admitted on [DATE] with diagnoses including schizophrenia (a mental disorder having delusions, hallucinations, disorganized thoughts, speech and behavior), dementia and anxiety. His mother was his legal guardian. Review of the admission packet and agreement dated 05/16/13 revealed Resident #12's legal guardian signed for resident rights including that the center must ensure the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the center. There 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 · E2023-05-24 · tag F0640 — patternEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure resident assessments were timely completed and transmitted to the Centers for Medicare and Medicaid Services (CMS) System. This affected four (Residents #18, #30, #37 and #42) of 24 residents reviewed for resident assessments. The facility had a census of 50 residents. Findings include: 1. Review of the medical record for Resident #18 revealed an admission date of 02/14/11 with diagnoses including schizoaffective disorder (a mental disorder that has symptoms of both schizophrenia and bipolar) and personal history of traumatic brain injury. Review of the Minimum Data Set (MDS) 3.0 Assessments for Resident #18 revealed he had a quarterly assessment dated for 04/12/23. The assessment was completed on 04/26/23 and stated export ready, however, had not been transmitted to the CMS system within 14 days. Interview on 05/21/23 at 3:24 P.M. with Licensed Practical Nurse (LPN) #807 verified Resident #18's quarterly MDS assessment dated [DATE] was 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 · E2023-05-24 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide 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 observations, interviews and record review, the facility failed to ensure staff assisted residents with grooming and provide showers per resident preference and schedule. This affected four (Residents #12, #24, #30 and #34) of four reviewed for activities of daily living. The facility had a census of 50 residents. Findings include: 1. Review of the medical record for Resident #12 revealed an admission date of 05/16/13 with diagnoses including Schizophrenia, diabetes mellitus, depression and dementia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #12 revealed he had impaired cognition. He needed extensive assistance of one staff member for toileting, limited assistance of one staff member for personal hygiene and physical help of one staff member during bathing. Review of the facility shower schedule, undated, revealed Resident #12 was to have showers on Mondays and Thursdays on dayshift. Review of the State Tested Nurse Aide (STNA) Point of Care (POC)…
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 before2023-05-24 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to ensure a clean and well-maintained environment. This affected six residents (Resident #3, #5, #12, #23, #27, and #45) with the potential to affect all 50 residents residing in the facility. Findings include: 1. Observation on 05/21/23 at 8:45 A. M. revealed Resident #3's wheelchair was dirty with dust and dried food on it. Observation verified by Registered Nurse (RN) #843 at time of observation was dirty. 2. Observation on 05/21/23 at 8:48 A.M. revealed Resident #5's chest harness restraint and wheelchair was dirty with dust and dried food on it. Interview at time of observation with State Tested Nursing Assistant (STNA) #900 stated she was not sure how to clean the chest harness restraint. 3. An environmental tour was conducted on 05/22/23 from 09:40 AM to 10:05 AM with confirmation from Maintenance Director #808 and Housekeeping Supervisor #847 of the following concerns: a. liquid splatter on hallway walls in the dining room and outside of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-24 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the 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 and interview, the facility failed to notify Resident #2's guardian of a new reddened chapped area on her chin, failed to notify Resident #5's guardian and physician of a new restraint order and failed to notify Resident #30's guardian of an open area on the back of his left hand. This finding affected three (Residents #2, #5 and #30) of three residents reviewed for notification of changes. Findings include: 1. Review of Resident #2's medical record revealed she was readmitted on [DATE] with diagnoses including cerebral palsy, unspecified intellectual disabilities and bipolar disorder. Review of Resident #2's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she exhibited moderate cognitive impairment. Review of Resident #2's medical record revealed she had a legal guardian who was her responsible party. Observation on 05/21/23 at 11:29 A.M. revealed Resident #2 had a rash under her chin area. Interview on 05/21/23 at 11:40 A.M. with Registered Nurse (RN) #809…
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 17 citations
- Potential for harm · D2023-05-24 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
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 and resident interview and policy review, the facility failed to ensure residents were free from physical restraints. This affected one (#5) of one resident reviewed for physical restraints. Findings include: Review of the medical record for Resident #5 revealed an admission date of 04/03/15 with diagnoses including but not limited to Huntington's disease, anxiety disorder, chronic pain syndrome, unspecified dementia, and peripheral vascular disease. Review of the restraint decision assessment dated [DATE] revealed Resident #5 had Huntington's Disease. She was constant motion and will twist in the chair or pitch forward. She enjoyed being up in wheelchair watching the comings and goings in the building. She can remove the chest harness restraint on demand. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/04/23, revealed Resident #5 had severely impaired cognition. The resident required extensive assistance of one staff for activities of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-24 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure Resident #11's annual comprehensive assessment was completed timely. This finding affected one (Resident #11) of twenty-four residents reviewed for comprehensive assessments. Findings include: Review of Resident #11's medical record revealed he was admitted on [DATE] with diagnoses including antisocial personality disorder, major depressive disorder and chronic obstructive pulmonary disease. Review of Resident #11's annual Minimum Data Set (MDS) 3.0 comprehensive assessment dated [DATE] indicated the assessment was in progress. Interview on 05/21/23 with Licensed Practical Nurse (LPN) Assistant Director of Nursing (ADON) #807 confirmed Resident #11's annual MDS 3.0 comprehensive assessment dated [DATE] was not completed as required and it should have been completed by 05/06/23.
- Potential for harm · D2023-05-24 · tag F0638 — isolatedAssure that each resident’s assessment is updated at least once every 3 months.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure resident assessments were completed timely. This affected one (Resident #10) of 24 residents reviewed for resident assessments. The facility had a census of 50 residents. Findings include: Review of the medical record revealed Resident #10 was admitted on [DATE] with diagnoses including depression, anxiety and borderline personality disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] was noted to be in progress and had not been completed. Resident #10's last MDS quarterly assessment was dated 01/30/23. Interview on 05/21/23 at 3:24 P.M. with Licensed Practical Nurse (LPN) #807 verified Resident #10's MDS was not completed timely and should have been completed by 05/02/23. LPN #807 stated she had not completed the MDS as she still had some information to enter into the assessment.
- Potential for harm · Dcited before2023-05-24 · 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
Based on observation, interview and record review, the facility failed to ensure skin conditions were assessed and treated. This affected one (Resident #30) of one resident reviewed for skin conditions. Findings include: Review of the medical record for Resident #30 revealed an admission date of 08/25/21 with diagnoses including personal history of traumatic brain injury and cerebral infarction (stroke). Review of the care plan dated 08/25/21 and last revised on 04/18/23 for Resident #30 revealed he had the potential for alteration in skin integrity. There were no indications he had an open area to his left hand or that he picked at his skin. Review of the nursing progress notes dated from 05/20/22 through 05/17/23 for Resident #30 revealed staff had not documented on any open areas of skin to his left hand. Review of the weekly skin observations for 05/06/23, 05/13/23 and 05/19/22, revealed Resident #30's skin to be intact. Observation on 05/21/23 at 9:17 A.M. revealed Resident #30 had an open area of skin to the top of his left hand. His left hand was noted to have an outline of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-24 · 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 and interview, the facility failed to ensure Resident #6 received adequate supervision to prevent the resident from eloping from the secured facility and failed to complete neurological assessments for Residents #30 and #36 after a fall. This finding affected one (Resident #6) of one resident reviewed for elopement and two (Residents #30 and #36) of three residents reviewed for falls. Findings include: 1. Review of Resident #6's medical record revealed he was admitted on [DATE] with diagnoses including schizoaffective disorder bipolar type, anxiety disorder, paranoid schizophrenia, and suicidal ideations. Review of Resident #6's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he exhibited intact cognition. Resident #6 had a guardian of person. Review of Resident #6's Police Report form dated 03/17/22 at 12:13 A.M. indicated a caller reported a male wearing all black was sitting on the curb near a main intersection. He was located walking southbound on the road and the male 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 · D2023-05-24 · 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 observation, record review and interview, the facility failed to ensure Resident #45's catheter care was completed as ordered. This finding affected one (Resident #45) of one resident reviewed for catheter care. Findings include: Review of Resident #45's medical record revealed he was admitted on [DATE] with diagnoses including hereditary spastic paraplegia, adjustment disorder with mixed anxiety and depressed mood and neuromuscular dysfunction of the bladder. Review of Resident #45's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he exhibited intact cognition and had an indwelling urinary catheter. Review of Resident #45's physician orders revealed an order dated 11/17/22 to flush the suprapubic catheter (a catheter inserted a couple of inches below the navel, or belly button, directly into the bladder, just above the pubic bone which allows urine to be drained without having a tube going through the genital area) with 30 cc (cubic centimeters) of 0.25% (percent) acetic acid solution every…
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 before2023-05-24 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to provide appropriate hand hygiene during incontinence care. This deficient practice affected one resident (Resident #5) out of one resident reviewed for incontinence care. The facility census was 50. Findings include: Review of Resident #5 medical record revealed resident was admitted to the facility on [DATE], with admission diagnoses including Huntington's Disease, anxiety disorder, seborrheic dermatitis, major depressive disorder, type 2 Diabetes Mellitus. Review of Resident #5 quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #5 required extensive assistance of one staff member for toileting, which included cleaning resident following incontinence episodes. Further review of the quarterly MDS revealed Resident #5 has a functional limitation in range of motion due to impairment on one side of her body. Review of Resident #5 Activities of Daily Living care plan revised date 04/26/23 revealed Resident #5 required assistance of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2020-03-12 · tag F0761 — failed to label and store drugs safely — widespreadEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review revealed the facility failed to ensure Tuberculin solution, solution used to test for tuberculosis (TB), was properly dated, used and disposed of according to manufacture guidelines. This affected nine residents, Residents #3, #11, #14, #19, #28, #33, #37, #39 and #47 and 26 new employees, State Tested Nurse Assistants (STNAs) #303, #304, #305, #307, #310, #311, #315, #316, #317, #319, #320, #321, #322, #324, #325, #326, #327, #328 and #329, Dietary Aides (DAs) #306, #308, #314, #318, Registered Nurse (RN) #309, Licensed Practical Nurse (LPN) #313, and the Administrator and had the potential to affect all 48 residents residing in the facility. Findings included: On 03/11/20 at 8:40 A.M. an observation of medication storage revealed the medication storage refrigerators had Tuberculin, Purified Protein Derivative (TB) solution, multi-vials received by pharmacy on 06/07/19. There were three open vials. One vial was not labeled with the open date, one vial was labeled with an open dated of 01/22/20 and one vial was labeled with an 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 · Fcited before2020-03-12 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, interview, and infection control guidelines, the facility failed to ensure bodily fluids were cleaned properly. This had the potential to affect all 48 of 48 residents that resided at the facility. Findings include: Observation 03/09/20 at 8:20 A.M. revealed Maintenance Director #331 was cleaning feces off the social services door with a towel, without wearing gloves. Interview with Maintenance Director #331 at that time confirmed the observation and concern. Review of the Centers for Disease Control and Prevention for Environmental Infection Control Guidelines, reviewed 05/14/19, revealed recommended cleaning strategies for spills of body fluids included for the worker assigned to clean up bodily fluids to wear gloves. Interview on 03/12/20 at 9:12 A.M. with the Director of Nursing confirmed staff should wear gloves while cleaning feces.
- Potential for harm · Fcited before2020-03-12 · tag F0921 — failed to keep a safe, functional, sanitary building — widespreadMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the environment was clean, sanitary, and in good repair. This affected Residents #4, #6 and #24 and had the potential to affect all 48 residents residing in the facility. Findings include: 1. Observation on 03/09/20 at 9:13 A.M. of Resident #4's room revealed a long, thin brown area with peeling white paint extending from the top of the wall to the middle of the ceiling. The brown area had two holes, one approximately 3 inches in diameter, and one approximately 2 inches in diameter. Interview on 03/09/20 at 11:22 A.M. with Resident #4 confirmed the ceiling had a brown area with peeling white paint and holes. Resident #4 stated the ceiling leaked water when it rained or snowed, and staff placed buckets in his room to collect the dripping water. He stated the buckets had been removed that morning. Interview on 03/09/20 at 11:30 A.M. with the Administrator revealed he was aware the ceiling leaked and needed repaired in Resident #4's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2020-03-12 · 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 and interview the facility failed to provide dressing changes for Resident #6's right knee abscess according to physician orders. This affected one of resident reviewed for skin conditions. Findings include: Resident #6 was admitted on [DATE] with diagnoses including but not limited to polyosteoarthritis, type two diabetes, peripheral vascular disease, psoriasis, and presence of artificial knee joint. Review of Resident #6's annual Minimum Data Set (MDS) assessment dated [DATE] revealed he was alert, oriented and had intact cognition. This assessment indicated he also had an open lesion. Resident #6's non-pressure ulcer skin report dated 03/06/20 revealed he had an abscess to his right knee. Review of Resident #6's physician orders from 03/03/20 through 03/10/20 revealed orders to apply sodium chloride solution, nine percent, to the right inner knee topically every day shift for a knee abscess, cleanse with normal saline, pay dry, apply Mesalt, a special type of dressing, cover with dry…
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 · D2020-03-12 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop 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 interview and record review, the facility failed to ensure Resident #17 was offered Prevnar 13 pneumococcal vaccination. This affected one (Resident #17) of five residents reviewed for immunizations. Findings include: Resident #17 was admitted on [DATE] with diagnoses including but not limited to major depressive disorder, psychosis, and Alzheimer's disease. Resident #17 was [AGE] years old. Review of Resident #17's immunization history revealed she received the Pneumovax vaccine on 03/18/18. There was no evidence Resident #17 was offered the Prevnar 13 pneumococcal vaccine, a vaccine effective against 13 different strains of pneumonia. Interview on 03/10/20 at 2:51 P.M. with the Director of Nursing revealed the facility had not been offering Prevnar 13 vaccines, and confirmed Resident #17 specifically had not been offered the Prevnar 13. Review of the facility policy titled,Pneumococcal Vaccine, undated, revealed the Centers for Disease Control and Prevention recommends vaccination with 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 · Fcited before2019-02-13 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, and record review, the facility failed to prepare and distribute food in a sanitary manner This had the potential to affect all 50 residents residing in the facility. Findings include: Observations during the initial tour of the kitchen on 02/10/19 from 9:30 A.M. to 9:49 A.M. with Dietary Manager (DM) #55 revealed two plastic dish racks sitting on the clean side of the dish machine. The dish racks were empty, slightly frayed, and appeared dirty, with tannish, brown buildup. The microwave appeared old and in the inside back bottom corners there where quarter sized rust stains. The industrial sized can opener had a dried, reddish substance on the blade. Interview on 02/10/19 at 9:39 A.M. and 9:49 A.M. with DM #55 confirmed the above observations. DM #55 stated the tannish brown buildup on the dish racks was possibly lime buildup from the hard water. DM #55 stated the dish racks and the microwave needed to replaced and that the can opener blade needed to be cleaned. Review of the facility's policy titled, Environment revised September 2017…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2019-02-13 · tag F0921 — failed to keep a safe, functional, sanitary building — widespreadMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to maintain a clean, sanitary, and homelike environment. This had the potential to affect all 50 residents. Findings include: Upon entering the facility on 02/10/19 at 8:00 A.M. a strong odor of stale urine was noted. This odor was noted in the lobby and hallways to the conference room and in the conference room which was located between the library and physical therapy department. The conference room had cloth chairs which were dry and odor free. The origination of the odor was not determined. A tour of the facility on 02/10/19 between 9:00 A.M. to 9:30 A.M. revealed residents in various stages of activities of daily living. Staff were assisting residents with care. The facility had a strong, pervasive odor of stale urine. Interview on 02/10/19 at 9:30 A.M. with Resident #101 revealed it smelled like urine and bowel and the building needed to be torn down. Interview on 02/10/19 at 10:21 A.M. with Resident #6 revealed there was a strong…
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 · D2019-02-13 · 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
Based on record review and staff interview the facility failed to comply with Resident #51's code status This affected one of 19 sampled residents. Findings include: Review of the closed record for Resident #51 revealed a re-admission date of 03/26/18. Diagnoses included paranoid schizophrenia, idiopathic epilepsy, and peripheral vascular disease. Physician orders for December 2018 revealed a code status of Do Not Resuscitate Comfort Care Arrest (DNRCC- Arrest) dated 07/18/18. DNRCC- Arrest indicated the resident did not wish to receive cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. Review of the DNRCC form signed by both the physician and Resident #51's responsible party dated 07/19/18 revealed Resident #51's code status was DNRCC-Arrest. Review of the care plan dated 07/31/18 revealed Resident #51 and family had chosen a DNR status and CPR measures would not be attempted during a cardiac arrest. Review of nursing notes dated 12/18/18 at 7:07 P.M. revealed at 6:25 P.M. Licensed Practical Nurse (LPN) #11 was notified Resident #51 was leaning in…
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 before2019-02-13 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview the facility failed to ensure proper infection prevention while passing meal trays to residents who ate in their rooms. This affected two of six residents whose meals trays were delivered to their room, Residents #26 and #18. Findings include: Observation on 02/10/19 at 1:06 P.M. revealed State Tested Nursing Assistant (STNA) #38 remove a lunch tray from the transport cart, walk into Resident #43's room, set the lunch tray on the bedside table, rub Resident's #43 chest to wake him up, and walk out of the room with out washing or sanitizing her hands. STNA #38 picked up another tray from the transport cart, walked into Resident #26's room, set up the lunch tray, put a clothing protector on Resident #26 and walked out of the room without washing or sanitizing her hands. STNA #38 proceeded back to cart and removed another tray, walked into Resident #18's room, set the lunch tray on the bedside table and walked out of the room without washing or sanitizing her hands. Interview with STNA #38 on 02/10/19 at 1:14 P.M. confirmed she did not wash or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2023-05-24 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to ensure accurate posted nurse staffing. This finding had the potential to affect all 50 residents currently residing in the facility. Findings include: Observation on 05/21/23 at 8:00 A.M. revealed the posted nurse staffing information was dated 03/15/23. Interview on 05/21/23 at 8:15 A.M. with Licensed Practical Nurse (LPN) Assistant Director of Nursing (ADON) #807 confirmed the facility did not appropriately display the accurate nursing staff information.
“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 EMBASSY HEALTHCARE — 33 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 2.4 | +0.6 vs chain |
| Health inspection | 2 of 5 | 2.1 | -0.1 vs chain |
| Staffing | 2 of 5 | 1.8 | +0.2 vs chain |
| Quality measures | 5 of 5 | 4.4 | +0.6 vs chain |
The other 32 homes this chain runs (chain average 2.4★, 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 |
|---|---|---|---|---|
| BARTLEBAUGH, THOMAS | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER | 12% | since 11/13/2006 |
| HANDLER, AARON | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER | 60% | since 11/13/2006 |
| KRUTOWSKY, STEPHEN | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 28% | since 11/13/2006 |
| HOFFMAN, JILL | Individual | W-2 MANAGING EMPLOYEE | — | since 11/13/2006 |
CMS files one row per role, so the 7 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.
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 366183. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2023-05-24, 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.