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Ohio Living Swan Creek

1650 Swan Creek Lane, Toledo, OH 43614 · For profit - Corporation · 34 certified beds · (419) 865-4445 Medicare & Medicaid certified

Call the home — (419) 865-4445 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0605) — cited Apr 2026Behavioral-health or dementia-care citation — no harm found (F0758)2 actual-harm citations$34,873 in federal fines
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $34,873 in federal fines (most recent 2025-08-27)
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (2/5)

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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 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, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Urgent care / clinic
1421 S Reynolds Rd · (419) 725-3562 · Call to confirm hours
Pharmacy
Walgreens0.4 mi
1910 S Reynolds Rd · (419) 867-3529 · Call to confirm hours
Grocery
4760 Glendale Ave · (419) 382-6372 · Call to confirm hours
Park
5604 Swan Creek Dr · Typically dawn to dusk
Place of worship
5025 Glendale Ave

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

Quality measures — how residents actually fare

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

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 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.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased2.6%5.3%15.4%better than state — see note marked double-dagger below the table
Long-stay residents who lose too much weight5.3%6.2%5.4%typical
Long-stay residents with a catheter left in their bladder0.0%0.2%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.4%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms6.8%30.1%6.5%typical
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury6.1%3.2%3.3%worse
Long-stay residents on antianxiety or hypnotic medication21.1%25.5%18.9%worse
Long-stay residents given the seasonal flu vaccine88.9%94.5%95.3%typical
Long-stay residents with pressure ulcers4.8%3.4%4.7%typical
Long-stay residents with worsening bladder/bowel control3.6%21.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table10.8%8.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine85.5%75.6%79.4%typical
Short-stay residents rehospitalized after admission28.7%24.9%22.6%worse
Short-stay residents with an outpatient ER visit20.5%12.9%12.0%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.

65.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 52 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

65.7%U.S. median 51.5%
Got home and stayed home
9.2%U.S. median 10.7%
Went back to hospital
57.1%U.S. median 56.6%
Met the expected recovery
0.42U.S. median 0.31
Therapy hours / resident / day
0.15hours / resident / day
Physical therapy
0.21hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 57.1% 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 28 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 0.42 therapist hours per resident per day in 2026Q1 — more than 71% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 29% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF65.7%CMS range 52.8–75.451.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.2%CMS range 6.0–14.110.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge57.1%56.6%Oct 2024–Sep 2025CMS 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 discharge64.3%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge64.3%50.0%Oct 2024–Sep 2025CMS 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 identified97.5%98.7%Oct 2024–Sep 2025CMS 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 setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay2.5%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.5%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.2%CMS range 3.1–12.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.941.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.86
RN hours/ resident / day
1.00
LPN hours/ resident / day
2.17
Aide hours/ resident / day
4.02
Total nurse hours/ resident / day
0.43
RN hoursweekends
45.7%
Total nursing turnover
25.0%
RN turnover

How full it usually is: this home is certified for 34 beds and averages 31.7 residents a day — about 93% occupied, or roughly 2 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 4.02 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.86 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.17 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 3.48 hrs/resident/day on weekends vs 4.24 on weekdays — 18% thinner on weekends. RN hours go from 1.03 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 46% is about the same as the national median of 45%.

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

Inspection trend

8
deficiencies at the latest standard inspection (2026-04-02)
8
at the previous standard inspection (2023-05-04)

Deficiencies are unchanged from the previous inspection. 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.

ABCDEFGHIJKL

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

25 citations, most serious first. The 12 most serious are shown; the remaining 13 are one tap away and print in full.

  • Actual harm · Gcited before2025-08-27 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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, family interview, staff interviews, and policy review, the facility failed to ensure a resident who experienced an unwitnessed fall with injury was provided timely treatment including notifying the physician of complaints of pain, inability to fully move extended leg and obtaining an x-ray. Actual harm occurred on 05/31/25, when Resident #30 experienced an unwitnessed fall from the bed with an injury. Following the incident, the resident continually complained of pain in his hip and had limited mobility with his leg. The facility did not obtain an x-ray of the hip until nine (9) days after the fall. Subsequently, Resident #30 was transferred to the hospital for surgical repair of a broken hip from the fall. This affected one (#30) of three residents reviewed for change in condition. The facility census was 28.Findings include:Review of the medical record for Resident #30 revealed an admission date of 02/24/24 and a discharge date of 06/13/25. admission diagnoses for Resident #30…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2023-10-31 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure physician orders for a nutritional supplement were followed and the physician and dietician were notified regarding a significant weight loss. This resulted in actual harm when Resident #3's ordered nutritional supplement was not available from the supplier for the facility to administer, the facility did not reach out to the physician or the dietician for an alternate supplement or different interventions, and the resident had a significant weight loss of 15.2 pounds/ 8.5 percent weight loss. Additionally, when the significant weight loss occurred the facility failed to notify the physician and dietician of the occurrence. This affected one (#3) of three residents reviewed for weight loss. The facility census was 28. Findings include: Review of Resident #3's medical record revealed an admission date of 06/10/23. Diagnoses included Parkinson, cognitive communication deficit, dysphagia, and Lewy body dementia. Review of the quarterly Minimum Data Set (MDS) assessment, dated…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2026-04-02 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and review of facility policy the facility failed to store and handle food safely. This had the potential to affect all residents. The census was 32.Findings include: 1. Observation on 03/30/26 at 7:34 A.M. of the main kitchen revealed in the walk-in refrigerator baby carrots stored in a plastic container and chopped celery stored in a plastic container were not labeled or dated, two opened bags of cubed cheese were not dated, and the stand-alone freezer included an opened personal water bottle. Interview on 03/30/26 at 7:45 A.M. with Assistant Dietary Manager #350 verified the carrots, celery, and two opened bags of cubed cheese were not labeled or dated and verified the personal water bottle in the stand-alone freezer. Review of the policy, Food Storage, dated 2023, verified leftover food should be stored in a covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated. All foods should be covered, labeled and dated and routinely monitored to assure that foods will be consumed by their use by…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-04-02 · tag F0605 — failed to not use drugs as a restraint — pattern
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, staff interview, pharmacist recommendations, and policy review, the facility failed to ensure adequate monitoring for psychotropic medication effectiveness, side effects and adverse effects. This affected four (#5, #13, #32, and #38) of five residents reviewed for unnecessary medications. This had the potential to affect 24 residents the facility identified as receiving psychotropic medications. The facility census was 32.Findings include: 1. Review of Resident #13's medical record revealed the resident was admitted to the facility on [DATE] with the diagnosis including heart failure, respiratory disorders, nonrheumatic mitral valve insufficiency, depression, unspecified sequalae of cerebral infarction, presence of cardiac pacemaker, shortness of breath, and dysphagia following cerebral infarction. Review of the most current minimum data set assessment (MDS) dated [DATE] Resident #13 had moderately impaired cognition, required staff assistance for all activities of daily…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-02 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, review of beneficiary protection notifications, and review of CMS (Centers for Medicare and Medicaid Services) guidance, the facility failed to ensure beneficiary protection notification included the estimated cost. This affected three (#11, #43, and #45) of three residents reviewed for beneficiary protection notice. The facility census was 32. Findings include:1. Review of the closed medical record revealed Resident #11 was admitted on [DATE] and discharged on 01/02/26. Diagnoses included acute respiratory failure with hypoxia, acute on chronic diastolic heart failure, and chronic kidney disease. Review of the Minimum Data Set (MDS) assessment, dated 01/02/26, revealed Resident #11 was cognitively intact.Review of the Advanced Beneficiary Notice of Non-coverage (ABN), signed 012/29/25, revealed Medicare may not pay for skilled services effective 01/01/26. The estimated cost was room and board plus therapy at $5.00 a minute. Resident #11 selected option three to…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-02 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, staff interview, and policy review, the facility failed to ensure comprehensive care plans reflected each resident's individual needs and conditions. This affected two (#3 and #5) of 17 residents reviewed for comprehensive care plans. The facility census was 32.Findings include:1. Review of the medical record for Resident #3 revealed an admission date of 12/05/25 with diagnoses of cerebral atherosclerosis, psychosis, chronic obstructive pulmonary disease, and congestive heart failure. Review of the comprehensive significant change Minimum Data Set (MDS) assessment, dated 03/10/26, revealed Resident #3 had impaired cognition and required partial/moderate assistance for bed mobility, had one unstageable (slough and/or eschar) wound and one unstageable deep tissue injury(DTI) (purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler than adjacent tissue). Further review revealed no rejection of care occurred during the lookback period.Review…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-02 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, record review, and policy review, the facility failed to ensure dependent residents received adequate oral hygiene. This affected one (#19) of two residents reviewed for activities of daily living.Findings include:Review of the medical record for Resident #19 revealed an admission date of 09/11/24 with diagnoses of dementia, anxiety, and heart failure.Review of the quarterly Minimum Data Set assessment, dated 01/09/26, revealed Resident #19 had impaired cognition, and required substantial/maximal assistance for oral hygiene.Review of the care plan, initiated 09/12/24, and revised 03/17/26, revealed Resident #19 will resist care with personal care and medications. Interventions included re-direct and re-approach as needed. Further review revealed Resident #19 required substantial/maximal assistance for personal hygiene and oral hygiene.Observation and interview on 03/30/26 at 10:43 A.M. Revealed Resident #19 sitting in a wheelchair in the common area. Resident #19 appeared groomed. Resident #19 stated the care she received was good. Observation…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-02 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide 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, record review, review of a delivery invoice, staff interview, and policy review, the facility failed to ensure wound treatments were implemented timely and failed to ensure pressure ulcer prevention devices were in place. This affected one (#3) of two residents reviewed for pressure ulcers. The facility census was 32.Findings include:Review of the medical record for Resident #3 revealed an admission date of 12/05/25 with diagnoses of cerebral atherosclerosis, psychosis, chronic obstructive pulmonary disease, and congestive heart failure. Review of the comprehensive significant change Minimum Data Set (MDS) assessment, dated 03/10/26, revealed Resident #3 had impaired cognition and required partial/moderate assistance for bed mobility, had one unstageable ( Pressure ulcer known but not stageable due to coverage of wound bed by slough and/or eschar.) wound and one unstageable deep tissue injury (DTI)( Purple or maroon area of discolored intact skin due to damage of underlying soft tissue. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-02 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, review of pharmacy recommendations, and staff interview, the facility failed to ensure pharmacy recommendations were addressed by the facility's provider. This affected one (#5) of five residents reviewed for pharmacy recommendations. The facility census was 32.Findings include:Review of the medical record for Resident #5 revealed an admission date of 08/01/25 with diagnoses of pain, stroke, hypertension, depression, and insomnia.Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/30/26, revealed Resident #5 had intact cognition and received an antidepressant and an opioid.Review of the current physician order's revealed Resident #5 received Duloxetine (an antidepressant) capsule, delayed release, 60 milligrams (mg)) 1 capsule orally once daily, dated 10/01/25, and Hydrocodone-Acetaminophen - Schedule II tablet (an opioid), 10-325 mg, 1 tablet by mouth every six hours as needed, dated 10/03/25.Review of a recommendation from the pharmacist to the physician, dated 10/02/25, revealed recommendations to monitor for behaviors with psychotropic use…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-02 · tag F0881 — failed to use antibiotics responsibly — isolated
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, staff interview, and policy review, the facility failed to ensure residents received appropriate antibiotics to treat urinary tract infections. This affected two (#26 and #44) of three residents reviewed for urinary tract infections (UTI). The facility census was 32.Findings include:1. Review of the medical record for Resident #26 revealed an admission date of 07/22/25 with diagnoses of Parkinson's disease with dyskinesia, dementia, and urinary tract infection. Review of the comprehensive annual Minimum Data Set (MDS) assessment, dated 02/02/26, revealed Resident #26 had intact cognition and was on an antibiotic. Review of the discontinued physician order, dated 01/29/26 through 02/03/26, revealed Resident #26 received Macrobid (nitrofurantoin monohydrate/macrocrystals) (an antibiotic) capsule: 100 milligrams (mg), one capsule by mouth twice daily for UTI.Interview on 04/01/26 at 2:14 P.M. with Unit Manager/Infection Preventionist (UM/IP) #317 and concurrent review of Resident #26's laboratory test obtained to diagnose a UTI, results dated 01/29/26, revealed…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-27 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide 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 review of medical records, family interview, staff interview, rand review of policy, the facility failed to provide interventions to prevent the development of a pressure ulcer. This affected one (#31) of three residents reviewed for pressure ulcers. The facility census was 28.Findings include: Review of the medical record for the Resident #31 revealed an admission date of 05/13/25 with diagnoses including aftercare following joint replacement surgery, unilateral primary osteoarthritis-left hip, unspecified fall, generalized muscle weakness, need for assistance with personal care, cognitive communication deficit, dementia, hypotension, pain due to internal orthopedic prosthetic devices, other specified personal risk factors, presence of left artificial hip joint, stage three chronic kidney disease, colostomy, malignant neoplasm, unspecified vitamin deficiency, anxiety, other specified depressive episodes, overactive bladder, and personal history of irradiation. The resident was discharged on…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-27 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and staff interview, the facility failed to ensure interventions were implemented timely to address incontinence. This affected one (#11) of four residents reviewed for timely care and treatment in a facility census of 29. Findings include:Review of the medical record revealed Resident #11 admitted to the facility on [DATE] with the diagnoses including, left humerus fracture, history of fall, rhabdomyolysis, muscle weakness, unspecified kidney injury, urinary tract infection, cerebral infarction, aphasia, coronary artery disease, atrial fibrillation, and congestive heart failure. Review of the most current Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 was assessed with severe cognitive impairment, was dependent on staff for the provision of activities of daily living (ADLs), and was incontinent of bowel and bladder.Review of a nursing plan of care dated 07/16/25 revealed a focus area to address Resident #11's bladder incontinence related to…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 13 citations
  • Potential for harm · Dcited before2024-04-29 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure the treatment of a suprapubic catheter was provided per physician order and failed to ensure the documentation of urine output was completed per physician order. This affected two (#20 and #22) of two residents reviewed for urinary catheters. The facility census was 37. Findings include: 1. Review of the medical record for Resident #22 revealed an admission date of 10/10/17. Diagnoses included neuromuscular dysfunction of the bladder, benign prostatic hyperplasia, and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was moderately cognitively impaired, required substantial assistance from staff with toileting, had an indwelling catheter, and had occasional bowel incontinence. Review of the care plan revised on 03/08/24 revealed Resident #22 required a suprapubic catheter related to urinary retention and a history of meatus erosion.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-29 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, staff interview, and review of the facility policies, the facility failed to implement enhanced barrier precautions when providing catheter care to the residents. This affected two (#20 and #22) of two residents observed for catheter care. The facility identified two residents (#20 and #22) with indwelling catheters. The facility census was 31. Findings include: 1. Review of the medical record for Resident #22 revealed an admission date of 10/10/17. Diagnoses included neuromuscular dysfunction of the bladder, benign prostatic hyperplasia, and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was moderately cognitively impaired, required substantial assistance with toilet hygiene, had an indwelling catheter, and had occasional bowel incontinence. Review of the care plan revised on 03/08/24 revealed Resident #22 required a suprapubic catheter related to urinary retention and a history of meatus erosion. Interventions…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-31 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately 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

    Based on medical record review, family interview, staff interview, and review of facility policies, the facility failed to notify the physician and resident representative of a significant weight loss for one (#3) of three residents reviewed for weight loss. The facility census was 28. Findings include: Review of Resident #3's medical record revealed an admission date of 06/10/23. Diagnoses included Parkinson, cognitive communication deficit, dysphagia, and Lewy body dementia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/18/23, revealed Resident #3 had severe cognitive impairment and required extensive assistance with activities of daily living, including eating. Review of a plan of care for Resident #3 initiated on 09/25/23, and revised on 10/26/23, revealed the resident was care planned for malnutrition related to decreased appetite and significant weight loss in 09/23. Review of physician orders for 09/23 revealed Resident #3 was on a regular, mechanical soft diet with thin liquids and Muscle Milk supplement twice daily. Review of weights for Resident #3…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-05-04 · tag F0921 — failed to keep a safe, functional, sanitary building — widespread
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and staff interview, the facility failed to ensure the shower was maintained in a clean and sanitary manner. This affected all residents except two (#2 and #12) residents identified by they facility as not using the shower room. The facility census was 31. Findings include: Observation on 05/01/23 at 11:05 A.M. of the shared resident shower room revealed a black substance on the caulk on the floor near the entrance to the shower and a brown and black substance in both back corners and along the walls, near the floor of the shower. Observation on 05/02/23 at 7:34 A.M. of the shared resident shower room revealed the substance remained on the floor and walls of the shower. Coinciding interview with State Tested Nurse Aide (STNA) #575 verified the substance in the shower, stating she believed it was mildew. STNA #575 stated aides were responsible to clean the area after each shower and housekeeping was responsible for doing a thorough cleaning each day. Further observation on 05/02/23 at 2:33 P.M. of the shower room revealed the substance remained on the floor and…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-05-04 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    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, beneficiary notice review, staff interview, and review of facility policy, the facility failed to ensure Notice of Medicare Non-Coverage was provided when Medicare Part A services ended and a resident remained in the facility. This affected one (#17) of three residents reviewed for beneficiary notices. The facility census was 31. Findings include: Review of Resident #17's medical record revealed an admission date of 10/04/21 and a readmission date of 03/30/23. Diagnoses included dementia, delusional disorder, hallucinations, hypotension, Parkinson's disease, cognitive communication disorder, difficulty in walking, repeated falls, hypertension, benign prostatic hyperplasia, delusional disorder, depression, and anxiety. Review of a significant change in condition Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was cognitively intact. Review of the Beneficiary Notice revealed Resident #17's last covered day for Medicare Part A services was on 04/19/23. Further…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-04 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and staff interview, the facility failed to ensure communication interventions were provided and available for use to increase communication abilities of one (#10) resident reviewed for impaired hearing and communication interventions. Facility census 31. Findings include: Review of the medical record revealed Resident #10 admitted to the facility on [DATE]. Diagnosis included severe dementia, neuromuscular urinary bladder dysfunction, hypertension, anemia, pulmonary fibrosis, pain, hydrocephalus, bilateral conductive hearing loss, major depression, and epilepsy. Review of the Minimum Data Set assessment, dated 03/21/23, assessed Resident #10 with severe cognitive impairment, moderate difficulty with hearing, no hearing aid or appliance used, clear speech, sometimes understood and understands, dependent on staff for the completion of activities of daily living, and utilizes a wheelchair for mobility. Review of the care plan dated 11/09/17 revealed supports and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-05-04 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and staff interview, the facility failed to ensure monitoring and interventions were implemented to promote the management of lower extremity edema. This affected one resident (#25) reviewed for bilateral lower extremity edema. Facility census 31. Findings include; Review of the medical record revealed Resident #25 admitted to the facility on [DATE]. Diagnoses included left femur fracture, anemia, spondylolithesis, osteoporosis, type II diabetes mellitus, hypertension, scoliosis, and unstageable pressure ulcer to left heel. Review of the Minimum Data Set assessment, dated 04/04/23, revealed Resident #25 was assessed with severely impaired cognition, clear speech and the ability to understand and be understood, no rejection of care behavior, dependent on staff for the provision of activities of daily living, requires extensive assistance of one staff for bed mobility and transfer. Review of nursing progress notes dated 03/14/23 at 1:37 P.M. noted Resident #25 admitted…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-05-04 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to ensure interventions were maintained to promote intact skin integrity. This affected one (#13 ) of five residents reviewed for skin breakdown prevention interventions. The facility identified 28 residents with preventative treatment for skin breakdown. The facility census was 31. Findings include: Review of Resident #13's medical record revealed an admission date of 06/01/22 and a readmission date of 02/06/23. Diagnoses included heart failure, atherosclerotic heart disease, hypertension, neuromuscular dysfunction of bladder, cerebral infarction, edema, history of falling and depression. Review of a significant change in condition Minimum Data Set (MDS) assessment, dated 02/13/23, revealed Resident #13 was cognitively intact, required extensive assistance with bed mobility, transfers, toilet use, and personal hygiene. In addition, Resident #13 was at risk of developing pressure ulcers and had no current pressure ulcers. Resident #13 had a pressure reducing device 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to ensure fall prevention interventions were provided in accordance with physician orders and per care plan. This affected two (#17 and #23) of two residents reviewed for the prevention of accidents. The facility census 31. Findings include: 1. Review of the medical record revealed Resident #23 admitted to the facility on [DATE]. Diagnoses included fracture to left femur, unspecified fall, calculus of kidney, muscle weakness, hypothyroidism, atrial fibrillation, edema, depression, urinary tract infection, and neuromuscular dysfunction of bladder. Review of the Minimum Data Set assessment, dated 03/21/23, revealed Resident #23 was assessed with intact cognition, was dependent on staff for the completion of activities of daily living including two or more staff for bed mobility and transfer According to a fall risk assessment completed on 03/14/23 Resident #23 was scored at high risk of sustaining…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-05-04 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and review of facility perineal care policy, the facility failed to ensure a resident received timely and proper incontinence. This affected one (#23) resident reviewed for incontinence care. The facility identified 26 incontinent residents. Facility census 31. Findings include; Review of the medical record revealed Resident #23 admitted to the facility on [DATE]. Diagnoses included fracture to left femur, calculus of kidney, hypothyroidism, atrial fibrillation, edema, depression, urinary tract infection, and neuromuscular dysfunction of bladder. Review of the Minimum Data Set assessment ,dated 03/21/23, Resident #23 had intact cognition, required the total dependence of staff for the completion of toileting, was incontinent of bowel and bladder, and had a urinary tract infection. Review of the nursing plan of care dated 07/16/23 revealed a plan of care to address Resident #23's functional urinary incontinence related to difficulty recognizing 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-05-04 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, observation, resident and staff interview, and review of facility policy, the facility failed to follow physician orders to provide a meal for one (#8) of one resident reviewed nutrition. The facility census was 31. Findings include: Review of Resident #8's medical record revealed an admission date of 02/22/23 and a readmission date of 04/06/23. Diagnoses included cognitive communication deficit, dysphagia, hypertension, paroxysmal atrial fibrillation, depression, dementia, malignant neoplasm of prostate, ileostomy status, gastrostomy status, and hypoxemia. Review of the Minimum Data Set (MDS) assessment, dated 04/13/23, revealed Resident #8 was moderately cognitively impaired and required extensive assistance with eating. In addition, Resident #8 had no significant weight loss, had a feeding tube, was on a mechanically altered diet, and received 25% or less of total calories through feeding tube. Review of a plan of care initiated 02/24/23 revealed Resident #8 required enteral nutrition and hydration, was now consuming meals in the dining room with…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2020-01-30 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to issue a written notice of bed hold policy to residents and resident representatives when transferred from the facility. This affected one (#20) of one resident reviewed for hospitalization. The facility identified six residents who were transferred to the hospital from the facility in the last three months. The census was 33. Findings include: Review of Resident #20's medical record revealed an admission date of 12/06/19. Diagnoses included acute bronchitis, retention of urine, iron deficiency anemia, muscle weakness, chronic kidney disease, and congestive heart failure. Review of an admission Minimum Data Set (MDS) assessment, dated 12/09/19, revealed Resident #20 had intact cognition. Review of a facility Bed Holds and Leaves of Absence for revealed Resident #20 indicated she wanted her bed held for any visits to hospitals, visits with friends or family, or any leaves of absence. Resident #20 signed the document on 12/06/19. Review of…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2020-01-30 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review and staff interview, the facility failed to provide rationale for an as needed psychoactive medication order extending beyond 14 days. This affected one (#3) of five residents reviewed for unnecessary medications. The facility identified six residents who received antianxiety medications. The census was 33. Findings include: Review of Resident #3's medical record revealed an admission date of 03/01/19. Diagnoses included unspecified dementia with behavioral disturbances, major depression, dysphagia, hypokalemia, and l hypertension. Review of an annual Minimum Data Set (MDS) assessment, dated 01/04/20, revealed Resident #3 had severely impaired cognitive skills for daily decision making and received an antianxiety medication seven days during the seven day look-back period. Review of a physician order dated 01/10/20 revealed Resident #3 was ordered the antianxiety medication Ativan 0.5 mg by mouth as needed daily with the instructions to give prior to stressful events such as appointments or procedures. There was no stop date for the as needed Ativan…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

$34,873 in federal fines across 1 penalty.

  • $34,873 — penalty dated 2025-08-27

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to OHIO LIVING COMMUNITIES — 11 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 54.4-1.4 vs chain
Health inspection 2 of 53.5-1.5 vs chain
Staffing 4 of 54.0≈ chain avg
Quality measures 5 of 54.9≈ chain avg
The other 10 homes this chain runs (chain average 4.4★, 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 / managerTypeRoleSince
ADAM, SANDRAIndividualCORPORATE DIRECTORsince 07/01/2019
BELFANCE, LESLIEIndividualCORPORATE DIRECTORsince 01/01/2023
INGWERSEN, MELISSAIndividualCORPORATE DIRECTORsince 07/01/2022
JOYCE, JAMESIndividualCORPORATE DIRECTORsince 07/01/2020
WHITE, TERRYIndividualCORPORATE DIRECTORsince 07/01/2019
GUMINA, LAURENCEIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 12/28/2011
STILLMAN, ROBERTIndividualCORPORATE OFFICERsince 04/15/2013
HUFDHI, RAIEDIndividualADP OF THE SNFsince 03/04/2025
PHILLIPS, TIMIndividualADP OF THE SNFsince 01/01/2019

CMS files one row per role, so the 10 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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.

$4.3M
Net patient revenuemost recent cost report
-11.0%
Operating marginrevenue minus expenses
$359K
Related-party expense8% of expenses
Who pays — share of resident-days
Medicaid 26%Medicare 8%Other / private 66%

This home reported $359K paid to related parties (affiliated landlords or management companies) in its most recent 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

$439per resident / day
operating cost
$13,333per month
≈ monthly operating cost
$395per day
avg. revenue, all payers

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

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 365996. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-02, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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