St Francis Senior Ministries
182 St Francis Ave, Tiffin, OH 44883 · Non profit - Church related · 54 certified beds · (419) 447-2723 Medicare & Medicaid certified
On the public record, this home looks stronger than most — but visit before you decide.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- lower-than-typical staff turnover (30% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 3.3% | 5.3% | 15.4% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 7.2% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.5% | 0.2% | 0.9% | worse 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 | 12.4% | 30.1% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 10.6% | 3.2% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 3.6% | 6.1% | 16.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 20.9% | 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 | 0.4% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 25.7% | 21.4% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 10.4% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.8% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 94.4% | 75.6% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 25.2% | 24.9% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 10.2% | 12.9% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.87 | 1.73 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.02 | 1.80 | 1.80 | worse |
‡ 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.
44.3% 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 46 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 57.6% 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 33 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 0.33 therapist hours per resident per day in 2026Q1 — more than 55% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 13% 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 | 44.3%CMS range 32.4–64.7 | 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 | 11.2%CMS range 8.2–15.0 | 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 | 57.6% | 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 | 60.6% | 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 | 45.5% | 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 | 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 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 | 3.3% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.4%CMS range 3.9–12.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.00 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 54 beds and averages 51.1 residents a day — about 95% occupied, or roughly 3 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.75 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.41 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.35 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 3.26 hrs/resident/day on weekends vs 3.95 on weekdays — 17% thinner on weekends. RN hours go from 0.49 to 0.23 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 30% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
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.
22 citations, most serious first. The 10 most serious are shown; the remaining 12 are one tap away and print in full.
- Potential for harm · F2025-04-10 · tag F0921 — failed to keep a safe, functional, sanitary building — widespreadMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based observation and staff interview the facility failed to ensure the facility was adequately maintained. This had the potential to affect all 52 residents residing in the facility. The facility census was 52. Findings include: • Observation on 04/10/25 from 8:09 A.M. through 9:05 A.M., during an environmental tour with the Administrator, revealed the following: • Outside the main elevator on the first floor, and continued down the hallway and into the dining room, were damaged and improperly fitted ceiling tiles. • Multiple ceiling tiles in the first floor dining hall, near the solarium opening, had dried water stains. • On the second floor, outside the main elevator and down the south hall (200-220 unit), and continued down the west hall (221-239 unit), were multiple water stained, damaged, and improperly fitted ceiling tiles. • On the first-floor memory care unit, fluorescent light ballast covers contained dirt and debris, including perished bugs and flies, and several covers were cracked with partially broken covers throughout both south and east halls. Concurrent interview…
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 before2025-04-10 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, review of the facility Self-Reported Incidents (SRIs), staff interview and review of facility policy, the facility failed to ensure staff implemented the facility's abuse policy related to immediate reporting of allegations of abuse to the Administrator. This affected one (#32) of one resident reviewed for abuse. The facility census was 52. Findings include: Review of Resident #32's medical record revealed an admission date of 07/28/23. Diagnoses including phantom limb syndrome with pain, chronic respiratory failure, and acquired absence of left leg above the knee. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/21/25, revealed a Brief Interview of Mental Status (BIMS) score of 14, indicating Resident #32 was cognitively intact. Review of the facility submitted SRI, created 01/26/25, revealed on 01/25/25, Resident #32 reported to Certified Nursing Assistant (CNA) #310 and Licensed Practical Nurse (LPN) #315 that at approximately 1:30 A.M., an unidentified staff member used force while applying cream to his left lower extremity…
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 · F2023-03-16 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — the official record, unedited, may be distressing
Based on staff interview and review of facility documentation, the facility failed to ensure facility daily staffing included a Registered Nurse (RN) for eight hours during a 24-hour period. This had the potential to affect all 79 residents residing in the facility. Findings include: Review of the facility's staffing schedules between 03/06/23 and 03/12/23 revealed the facility did not have a RN for eight hours in the 24-hour period on Sunday 03/12/23. Interview on 03/13/23 at 2:56 P.M. with the Administrator revealed the facility's staffing schedules were reviewed and the Administrator confirmed the facility lacked RN coverage for the entire day on 03/12/23 during a 24-hour period. This deficiency represents non-compliance investigated under Complaint Number OH00140552.
- Potential for harm · E2023-03-16 · 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, staff interview, and review of the facility policy, the facility failed to ensure resident medications were kept secured and out of reach of cognitively impaired and independently mobile residents. This affected one resident (#327) and had the potential to affect four additional residents who were cognitively impaired and independently mobile (#29, #49, #68, and #177) on the two-east hall. The facility census was 79. Findings Include: Observation on 03/15/23 at 4:07 P.M. revealed a medication cart located on two east was unlocked and unattended with loose pills in a clear plastic medication cup on top of the medication cart. Licensed Practical Nurse (LPN) #373 was approximately eight feet from the medication cart with his back turned toward the medication cart talking and joking with a resident and their family. Observation at this time, also revealed a cognitively impaired, independently mobile resident, Resident #177, seated in a recliner approximately four feet from the unlocked, unattended medication cart with loose pills in a medication cup on the top 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 · E2023-03-16 · 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 resident and staff interview, record review, observation of meal service, review of the facility menu, recipe review, and review of facility policy, the facility failed to ensure residents who received pureed meals from the second floor kitchen received the correct serving sizes. This affected five (#20, #24, #33, #36, and #177) of five residents who received pureed meals on the second floor. In addition, the facility failed to follow the approved menu and recipe during meal service. This affected all residents except 14 (#5, #12, #15, #20, #24, #33, #36, #59, #60, #64, #68, #177, #179, and #180) identified by the facility as not having the food items for which the recipe was not followed. The facility census was 79. Findings include: 1. Review of a facility document titled 2022 Fall/Winter Menus, undated, revealed the pureed lunch meal consisted of a number eight scoop of beef burgundy, a number eight scoop of egg noodles, and a number twelve scoop of key west vegetable blend for 03/13/23. Observation on 03/13/23 at 11:30 A.M. of meal service in the second floor dining…
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 · E2023-03-16 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure 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, and policy review, the facility failed to ensure residents were served meals palatable to taste and temperature. This had the potential to affect all residents except nine residents (#20, #24, #33, #36, #59, #60, #64, #68, and #177) who received alternative meals or were on a pureed diet. The facility census was 79. Findings include Interview on 03/13/23 at 9:59 A.M. with Resident #54 revealed the facility food was served cold. Interview on 03/13/23 at 12:36 P.M. with Resident #1 stated the food was cold sometimes. Resident #1 further stated staff would put hot food on cold plates. Observation on 03/13/23 at 4:25 P.M. revealed [NAME] #349 took the temperature of the pizza and the garlic bread. The pizza was 167 degrees Fahrenheit (F) and the garlic bread was 187 degrees F. Observation and interview on 03/13/23 at 4:40 P.M. of dinner service revealed [NAME] #349 was plating meals. Further observation revealed the plate warmer was not on. [NAME] #349 verified the plate warmer was not on. [NAME] #349 then flipped the plate warmer…
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 · D2023-03-16 · 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 medical record review, staff interview, and review of the facility guideline, the facility failed to notify the physician when a resident tested positive for COVID-19 and when a resident sustained an abrasion. This affected two residents (#6 and #7) of two residents reviewed for notification of change. The facility census was 79. Findings include: 1. Review of Resident #6's medical record revealed an admission date of 08/04/21. Diagnoses included chronic obstructive pulmonary disease (COPD), atherosclerotic heart disease, and congestive heart failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was cognitively intact. Review of a nursing progress note dated 02/04/23 revealed Resident #6 requested a COVID-19 test due to symptoms of cough, dry eyes, and congestion. The COVID-19 swab was positive. Further review Resident #6's progress notes and medical record from 02/04/23 through 02/06/23 revealed no documentation of physician notification of Resident #6'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 · D2023-03-16 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record review, and staff interview, the facility failed to ensure the resident's care plans were revised and updated with current interventions to address their care needs. This affected two (Residents #35 and #71) of 19 residents reviewed for care plan revisions. The facility census was 79. Findings include: 1. Review of Resident #71's medical record revealed an admission date of 10/17/22. Diagnoses included Alzheimer's disease. Review of Resident #71's physician orders revealed an order dated 12/06/22 for a silent alarm to be in place at all times on day and night shift. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #71 was rarely or never understood. Resident #71 had a bed alarm and chair alarm that were used daily. Review of Resident #71's care plan revised 02/15/23 revealed supports and interventions for self-care deficit, impaired cognitive function, and risk for falls. Fall interventions included anticipate needs and call light in reach. 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 · D2023-03-16 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, resident and staff interview, and review of the facility policy, the facility failed to ensure residents who were dependent on staff for assistance received assistance with shaving and nail care. This affected one (#60) of one residents reviewed for activities of daily living (ADLs). The facility identified 73 residents who required assistance from staff with bathing and 70 residents who required assistance with dressing. The facility census was 79. Findings include: Review of Resident #60's medical record revealed a re-admission date of 02/23/22. Diagnoses included congestive heart failure (CHF), acquired absence of left leg above the knee, morbid obesity, and chronic obstructive pulmonary disease (COPD). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 was cognitively intact and required extensive assistance from staff with dressing, and personal hygiene. Resident #60 had no refusals of care during the review period.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-16 · 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, staff interview, and review of the facility's guideline and policy, the facility failed to ensure interventions were implemented timely to promote wound healing and prevent further skin injury. This affected one (Resident #7) of one resident for non-pressure related skin issues. The facility census was 79. Findings include: Review of Resident #7's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic kidney disease stage, lymphedema, type II diabetes mellitus, peripheral vascular disease (PVD), non-pressure chronic ulcer lower extremities, edema, morbid obesity, neuropathy, chronic embolism and thrombosis right popliteal vein. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had intact cognition, independent with activities of daily living, utilized a walker and wheelchair for locomotion, was at risk for pressure ulcer development, and had four venous and arterial ulcers involving…
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 12 citations
- Potential for harm · D2023-03-16 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, review of the facility policy, and review of the manufacturer user manual, the facility failed to ensure skin pressure relieving interventions were implemented timely and in accordance with device instructions for use. This affected one (Resident #24) of three residents reviewed for the prevention and healing of skin breakdown. The facility identified two residents with pressure ulcers and 74 residents receiving preventative skin care. The facility census was 79. Findings include: Review of Resident #24's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, anxiety disorder, congestive heart failure, and bone density disorder. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 had intact cognition, required the extensive assistance of one staff for activities of daily living, incontinent of bladder, and was at risk 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 · D2023-03-16 · 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 observations, medical record review, and staff interview, the facility failed to ensure residents were assessed and provided care and treatment to maintain normal bladder function, including timely incontinence care. This affected two (Residents #24 and #38) of two residents reviewed for bowel and bladder continence. The facility census was 79. Findings include: 1. Review of Resident #38's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, left side hemiplegia, paranoid schizophrenia, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 had moderately impaired cognition, dependent on staff for the completion of activities of daily living including toileting, incontinent of bladder, continent of bowel, and was at risk for pressure ulcer development with no skin breakdown. Review of the nursing plan of care dated 08/29/19 revealed it was initiated to address Resident #38's incontinence 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 · E2019-09-19 · tag F0623 — patternProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to issue written notice of the reasoning for transfer to the hospital to the resident and/or resident representative. This affected five (#9, #36, #49, #100 and #112) of five residents reviewed for hospitalizations. The facility census was 115. Findings include: 1. Review of Resident #9's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included unspecified sepsis, difficulty walking, unspecified ileus, pressure ulcer - sacral stage four, acute kidney failure, diabetes mellitus, non-inflammatory vaginal disorder, gastrostomy, dysphagia, moderate protein calorie malnutrition, gait and mobility abnormalities, hyperlipidemia, hyperosmolality, hypernatremia, hypokalemia, affective mood disorder and unspecified intellectual disabilities. Review of the medical record for Resident #9 revealed the resident was transferred to the hospital on [DATE] at 3:51 P.M. Resident #9 returned to the facility on [DATE] at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2019-09-19 · tag F0625 — patternNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to issue written notice of the reasoning for transfer to the hospital to the resident and/or resident representative. This affected five (#9, #36, #49, #100 and #112) of five residents reviewed for hospitalizations. The facility census was 115. Findings include: 1. Review of Resident #9's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included unspecified sepsis, difficulty walking, unspecified ileus, pressure ulcer - sacral stage four, acute kidney failure, diabetes mellitus, non-inflammatory vaginal disorder, gastrostomy, dysphagia, moderate protein calorie malnutrition, gait and mobility abnormalities, hyperlipidemia, hyperosmolality, hypernatremia, hypokalemia, affective mood disorder and unspecified intellectual disabilities. Review of the medical record for Resident #9 revealed the resident was transferred to the hospital on [DATE] at 3:51 P.M. Resident #9 returned to the facility on [DATE] at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-09-19 · tag 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 electronic medical record review, paper medical record review, staff interview, and the facility policy, the facility failed to ensure advanced directive status was documented accurately in the electronic medical record. This affected one (#100) of 32 residents reviewed for advanced directives. The facility census was 115. Findings include: Review of Resident #100's medical record revealed an admission date of 01/28/19. Diagnoses included diabetes, pressure ulcer right heel, muscle weakness, chronic kidney disease, and hypertension. Review of Resident #100's physician orders dated September 2019, revealed the orders did not list a code status for the resident. Further review of the electronic face sheet revealed no code status had been listed. Review of Resident #100's an undated Do Not Resuscitate Comfort Care Arrest (DNRCC-A) paper form revealed the form was signed by a physician indicating Resident #100 was a DNRCC-A status. Review of Resident #100's Medication Administration Record (MAR) dated September 2019 revealed under the section titled advanced directives that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-09-19 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of facility Self-Reported Incident (SRI), staff and resident interviews, and facility policy review, the facility failed to follow their abuse policy to immediately report to the Administrator and investigate an incident of unknown origin for one resident (#97) identified in 12 SRI's reviewed. The facility census was 115. Findings include: Review of the medical record revealed Resident #97 was admitted to the facility on [DATE]. Diagnoses included chronic partial fibrillation, chronic obstructive pulmonary disease, and major depressive disorder Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/28/19, revealed the resident had no cognitive deficits. His vision was adequate with the use of corrective lens. He required extensive assistance with bed mobility and transfers. He was unable to ambulate. The assessment revealed he had no current skin conditions. Review of plan of care updated 08/28/19 noted the resident had an activity of daily living self care…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-09-19 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of facility Self-Reported Incident (SRI), staff and resident interviews, and facility policy review, the facility failed to report an injury of unknown origin for one resident (#97) identified in 12 SRI's reviewed. The facility census was 115. Findings include: Review of the medical record revealed Resident #97 was admitted to the facility on [DATE]. Diagnoses included chronic partial fibrillation, chronic obstructive pulmonary disease, and major depressive disorder Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/28/19, revealed the resident had no cognitive deficits. His vision was adequate with the use of corrective lens. He required extensive assistance with bed mobility and transfers. He was unable to ambulate. The assessment revealed he had no current skin conditions. Review of a facility SRI, dated 08/21/19, revealed Resident #97 was noted to have a black and blue eye on the left side. The the facility was unable to determine the cause of the black…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-09-19 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of facility Self-Reported Incident (SRI), staff and resident interviews, and facility policy review, the facility failed to investigate an incident of unknown origin for one resident (#97) identified in 12 SRI's reviewed. The facility census was 115. Findings include: Review of the medical record revealed Resident #97 was admitted to the facility on [DATE]. Diagnoses included chronic partial fibrillation, chronic obstructive pulmonary disease, and major depressive disorder Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/28/19, revealed the resident had no cognitive deficits. His vision was adequate with the use of corrective lens. He required extensive assistance with bed mobility and transfers. He was unable to ambulate. The assessment revealed he had no current skin conditions. Review of the medical record revealed no mention of Resident # 97 ever having a black eye. Review of a facility SRI, dated 08/21/19, revealed Resident #97 was noted to have a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-09-19 · 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 medical record review, interview and facility policy review the facility failed to complete a discharge summary for one (#121) of one resident reviewed for discharge summary. The facility census was 115. Findings include: Review of the medical record revealed Resident #121 was admitted to the facility on [DATE]. Diagnoses included of aftercare following surgery for neoplasm, hypertension, hemiplegia and anemia. Resident #121 was discharged from the facility on 08/10/19. Review of the physician order dated 08/10/19 revealed to discharge the resident to home per hospice. Review of the nurse progress notes revealed on 08/14/19 at 11:19 A.M. social worker was not able to assess resident. He was admitted on hospice and discharged home over the weekend with family. A note dated 08/12/19 at 9:49 A.M. and titled Discharge Summary included that Resident #121 was admitted to the facility on [DATE]. He was discharged on 08/10/19 prior to the activity assessment being completed. Further review of the nurse progress…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-09-19 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and staff interview, the facility failed to provide ongoing assessment and monitoring of non-pressure wounds and failed to complete physician ordered treatments to the wounds. This affected one (#320) of nine residents identified by the facility with non-pressure wounds. The facility census was 115. Findings include: Review of the medical record revealed Resident #320 was admitted to the facility on [DATE]. Diagnoses included non-pressure chronic ulcer of the left lower leg with fat layer exposed to the left calf, left foot and right leg, morbid (severe) obesity, diabetes, cellulitis of the left lower limb, chronic embolism and thrombosis of the right popliteal vein, peripheral vascular disease (PVD), and methicillin-resistant staphylococcus aureus (MRSA). Review of the admission Minimum Data Set (MDS) assessment, completed 09/12/19, revealed Resident #320 was cognitively intact. Resident #320 had no pressure wounds. Resident #320 had four venous ulcers and a diabetic…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-09-19 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to provide ongoing monitoring to validate the continued use of a statin medication for one (#63) of five residents reviewed for unnecessary medications. The facility census was 115. Findings include: Review of the medical record revealed Resident #63 was admitted to the facility on [DATE]. Diagnoses included Parkinson's disease, depression, diabetes, dementia, hypertension, anxiety and hyperlipidemia. Review of the physician orders revealed Atorvastatin Calcium Tablet 40 milligrams (mg) give one tablet by mouth at bedtime related to hyperlipidemia dated 06/25/19. Review of the laboratory (lab) results from 09/01/18 to 09/19/19 revealed Resident #63 had no lab test completed for cholesterol. Interview with Director of Nursing (DON) on 09/19/19 at 10:15 A.M. verified Resident #63 was prescribed Atorvastatin (a statin medication for high cholesterol levels). The DON verified Resident #63 did not have any lab testing for the continued use 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 · C2019-09-19 · tag F0868 — widespreadHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — the official record, unedited, may be distressing
Based on review of the facility's Quality Assessment and Assurance (QAA) meeting sign in documents and staff interview, the facility failed to ensure the medical director attended the QAA meetings on a quarterly basis. This had the potential to affect all 115 residents in the facility. Finding include : Review of the QAA quarterly sign in sheets dated 10/18/18, 01/24/19, and 07/17/19 revealed the Medical Director did not attend. Interview on 09/19/19 at 2:30 P.M. the Director of Nursing verified the Medical Director did no sign in as attending the quarterly QAA meeting on 10/18/18, 01/24/19, and 07/17/19 .
“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 CSJ INITIATIVES — 2 facilities. Here is how its ratings compare with the chain’s average across all its homes:
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 4.5 | -0.5 vs chain |
| Health inspection | 4 of 5 | 4.0 | ≈ chain avg |
| Staffing | 3 of 5 | 4.0 | -1.0 vs chain |
| Quality measures | 4 of 5 | 3.5 | +0.5 vs chain |
The other 1 home this chain runs (chain average 4.5★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| CSJ INITIATIVES INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | 100% | since 03/01/2019 |
| STOLL, GABRIEL | Individual | W-2 MANAGING EMPLOYEE | — | since 03/01/2019 |
| ALDRIDGE, SARA | Individual | CORPORATE DIRECTOR | — | since 03/01/2019 |
| ANDERSON, ELEANOR | Individual | CORPORATE DIRECTOR | — | since 03/01/2019 |
| ARNONE, MYRA | Individual | CORPORATE DIRECTOR | — | since 03/01/2019 |
| DARIANO, KELLI | Individual | CORPORATE DIRECTOR | — | since 03/01/2019 |
| FABRIZIO, DOMINIC | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 03/01/2019 |
| FALTER, BRIAN | Individual | CORPORATE DIRECTOR | — | since 03/01/2019 |
| GANNON, DENISE | Individual | CORPORATE DIRECTOR | — | since 03/01/2019 |
| GRIFFIN, JILL | Individual | CORPORATE DIRECTOR | — | since 03/01/2019 |
| KUCERA, JAN | Individual | CORPORATE DIRECTOR | — | since 03/01/2019 |
| MACK, SHELLIE | Individual | CORPORATE DIRECTOR | — | since 03/01/2019 |
| O'BRIEN, MARGUERITE | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 03/01/2019 |
| WEBB, TYLER | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 03/01/2019 |
| SLATER, WILLIAM | Individual | CORPORATE OFFICER | — | since 03/01/2019 |
CMS files one row per role, so the 19 rows in the source record cover these 15 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.
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 2024. 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, FY2024). 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 366102. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-10, 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.