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Otterbein Sunset House

4020 Indian Rd, Toledo, OH 43606 · Non profit - Corporation · 24 certified beds · (419) 536-4645 Medicare & Medicaid certified

Call the home — (419) 536-4645 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Oct 2024
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Oct 2024
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its payroll-based staffing rating is low (1/5)
  • nursing-staff turnover (64%) runs well above the national median (45%)

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 3 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
3130 Executive Pkwy · (419) 720-9000 · Call to confirm hours
Pharmacy
3234 Executive Pkwy Ste 111 · (419) 843-2100 · Call to confirm hours
Grocery
3315 W Central Ave · (419) 531-5218 · Call to confirm hours
Park
3301 Indian Rd · Typically dawn to dusk
Place of worship
3925 W Central Ave · (419) 536-3789

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
Short-stay residentsrehab / post-hospital 5 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
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 who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury8.3%3.2%3.3%worse
Long-stay residents with pressure ulcers5.2%3.4%4.7%worse
Long-stay residents with worsening bladder/bowel control27.7%21.4%21.2%worse
Short-stay residents who newly got an antipsychotic medication0.6%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine47.6%75.6%79.4%worse
Short-stay residents rehospitalized after admission45.1%24.9%22.6%worse
Short-stay residents with an outpatient ER visit7.2%12.9%12.0%better

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.

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.

59.2% 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 104 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

59.2%U.S. median 51.5%
Got home and stayed home
11.6%U.S. median 10.7%
Went back to hospital
71.4%U.S. median 56.6%
Met the expected recovery
1.21U.S. median 0.31
Therapy hours / resident / day
0.59hours / resident / day
Physical therapy
0.44hours / resident / day
Occupational therapy
0.18hours / resident / day
Speech therapy

Met the expected recovery: 71.4% 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 42 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 1.21 therapist hours per resident per day in 2026Q1 — more than 98% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 14% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF59.2%CMS range 50.0–65.351.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.6%CMS range 8.0–14.910.7%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 discharge71.4%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 discharge66.7%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 discharge35.7%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 identified100.0%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 setting90.9%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 discharge100.0%98.7%Oct 2024–Sep 2025CMS 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 stay0.0%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 worsened1.4%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 hospitalization7.5%CMS range 4.3–11.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.791.02Oct 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

1.18
RN hours/ resident / day
0.75
LPN hours/ resident / day
2.16
Aide hours/ resident / day
4.09
Total nurse hours/ resident / day
0.56
RN hoursweekends
64.3%
Total nursing turnover
66.7%
RN turnover

How full it usually is: this home is certified for 24 beds and averages 21.1 residents a day — about 88% 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 4.09 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.18 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.16 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 3.42 hrs/resident/day on weekends vs 4.36 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 1.42 to 0.56 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 64% is well above 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 (2025-05-01)
5
at the previous standard inspection (2022-08-25)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

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.

24 citations, most serious first. The 10 most serious are shown; the remaining 14 are one tap away and print in full.

  • Potential for harm · F2025-05-01 · tag F0727 — failed to provide required RN coverage — widespread
    Have 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 staffing documentation, the facility failed to ensure the facility was staffed with sufficient Registered Nursing staff each day. This affected all residents residing in the facility. Facility census was 14. Findings include: Review of facility nursing schedules between 04/21/25 and 04/27/25 revealed the schedule lacked documentation indicating a Registered Nurse (RN) was scheduled to work in the facility on 04/26/25 and 04/27/25. On 04/30/25 at 1:37 P.M. interview with the Administrator and Director of Nursing (DON) during a review of the nurse staffing scheduled between 04/21/25 and 04/27/25 verified the facility was not staffed with a Registered Nurse on 04/26/25 or 04/27/25. The Administrator stated the DON was on call on 04/26/25 and 04/27/25. However, the DON did not report to the facility on either date. On 05/01/25 at 7:50 A.M. review of facility weekly staffing sheet between 04/21/25 and 04/27/25 during interview with the DON confirmed no Registered Nurse was working in the facility on 04/26/25 and 04/27/25.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-05-01 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview, facility documentation, and a policy for water management, the facility failed to ensure a sufficient water management program based on an accurate risk assessment. This had the potential to affect all residents. The census was 14. Findings include: Review of a document titled Legionnaire's Risk Assessment revealed the document was undated, unsigned, and did not include the name of the facility. Interview on 05/01/25 at 9:15 A.M. with Administrator and Environmental Services Director #233 confirmed the risk assessment did not include the date of the assessment, a signature, or the name of the facility. Both denied knowledge of when the risk assessment was completed and by whom. Review of policy titled, Water Management Program for Legionella Risk Reduction, dated 2017, revealed the facility shall conduct a risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-05-01 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and review of fire drill reports, corrective action plans, and a state fire marshal report, the facility failed to conduct fire drills across all shifts during the twelve-month review period preceding the survey. This had the potential to affect all residents. The census was 14. Findings include: Interview on 05/01/25 at 9:15 A.M. with the Administrator and Environmental Services Director (ESD) #233 revealed fire drills were not conducted on first or third shift in the first quarter of 2024, and no fire drill was conducted on third shift in the third quarter of 2024. Follow-up interview on 05/01/25 at 1:15 P.M. with the Administrator revealed the state fire marshal issued a violation on 07/25/24 for failure to conduct fire drills across all shifts during each quarter. Review of the Emergency and Disaster Plan, last reviewed 11/26/24, confirmed fire drills are to be conducted monthly and rotated so drills are conducted on each shift at least once per quarter. The deficient practice was…

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

    Environmental Deficiencies · Past Non-Compliance
  • Potential for harm · D2025-05-01 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to ensure resident toilet facilities were maintained in a sanitary manner. This affected one of 14 residents (#125) reviewed for environmental and housekeeping services. Facility census was 14. Findings include: Resident #125 admitted to the facility on [DATE] with diagnoses including, nondisplaced right femur fracture, paranoid schizophrenia, type 2 diabetes mellitus, urinary tract infection, anemia, chronic kidney disease, hypertension, Alzheimer's disease, dementia, depression, coronary artery disease and heart failure. According to the functional abilities assessment dated [DATE] assessed Resident #125 to require substantial to maximal assistance with activities of daily living. On 04/26/25 skilled nursing charting assessed Resident #125 as alert and oriented to person and place, received oxygen via nasal cannula, continent of bowel and bladder, and unable to bear weight with unsteady gait. On 04/28/25 at 12:10 P.M. observation in Resident #125'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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-01 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure resident pharmacy medication regimen reviews were conducted monthly. This affected two of five sampled residents (#4, #1) reviewed for unnecessary medications and related pharmacy services in a facility census of 14. Findings include: 1. Resident #4 admitted to the facility on [DATE] with the diagnosis including, cerebral infarction resulting in hemiplegia and hemiparesis right side, dysphagia, abnormal posture, coronary artery disease, hypokalemia, congestive heart failure, glaucoma, atrial fibrillation, major depression, type 2 diabetes mellitus, and neuromuscular dysfunction of bladder. According to the most current Minimum Data Set (MDS) assessment dated [DATE] Resident #4 was assessed with severe cognitive impairment, no behaviors, dependent on staff for the completion of activities of daily living, incontinent of bowel and bladder, and received scheduled pain medications. Review of Resident #4's medical record noted current…

    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 · D2025-05-01 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure 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 ensure psychoactive medication recommendations were implemented as directed by the physician. This affected one of five sampled residents (#4) reviewed for the provision of unnecessary medication administration in a facility census of 14. Findings include: Resident #4 admitted to the facility on [DATE] with diagnoses including, cerebral infarction resulting in hemiplegia and hemiparesis right side, dysphagia, abnormal posture, coronary artery disease, hypokalemia, congestive heart failure, glaucoma, atrial fibrillation, major depression, type 2 diabetes mellitus, and neuromuscular dysfunction of bladder. According to the most current Minimum Data Set assessment dated [DATE] Resident #4 was assessed with severe cognitive impairment, no behaviors, dependent on staff for the completion of activities of daily living, incontinent of bowel and bladder, and received pain medications. On 12/13/16 a nursing plan of care was initiated to address…

    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 · Dcited before2025-05-01 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and facility policy, the facility failed to ensure medications were provided as ordered by the physician and without error. This resulted in three errors of 37 medications being administered with a 8.11% error rate. This affected one of three residents (#20) observed for medication administration in a facility census of 14. Findings include: Resident #20 admitted to the facility on [DATE] with diagnoses including, pneumonia, hypoxemia, fluid overload, type 2 diabetes mellitus, chronic obstructive pulmonary disease, long term use insulin, polyneuropathy, glaucoma, chronic kidney disease, hypertension and depression. According to the most current Minimum Data Set assessment dated [DATE] assessed Resident #20 with moderately impaired cognition, dependent on staff for the completion of activities of daily living, vision adequate with corrective lenses, and incontinent of urine. Review of physician orders noted the following; 03/18/25 Cilostazol Oral…

    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 · Dcited before2025-05-01 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    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 facility policy, the facility failed to ensure medications were administered to prevent the occurrences of significant medication errors. This affected two of four sampled residents (#20, #125) reviewed for the administration of medications in a facility census of 14. Findings include: 1. Resident #20 admitted to the facility on [DATE] with diagnoses including, pneumonia, hypoxemia, fluid overload, type 2 diabetes mellitus, chronic obstructive pulmonary disease, long term use insulin, polyneuropathy, glaucoma, chronic kidney disease, hypertension and depression. According to the most current Minimum Data Set assessment dated [DATE] assessed Resident #20 with moderately impaired cognition, dependent on staff for the completion of activities of daily living, vision adequate with corrective lenses, and incontinent of urine. Review of physician orders noted the following; 03/18/25 Cilostazol Oral Tablet 100 milligrams (mg) (Cilostazol) Give 1 tablet…

    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 · D2024-10-30 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of the facility policy, staff interview, and review of the facility self-reported incident, the facility failed to prevent staff-to-resident physical abuse. This affected one (Resident #1) of four residents reviewed for abuse. The facility census was 15. Findings include: Review of the medical record for Resident #1 revealed an admission date of 12/14/17. Diagnoses included peripheral venous insufficiency, polyarthritis, macular degeneration right and left eye, dementia, chronic kidney disease, hemiplegia and hemiparesis following a cerebral vascular accident. An additional diagnosis of cerebral atherosclerosis was added on 10/21/24. Review of the quarterly Minimum Data Set (MDS) assessment completed on 10/09/24 Resident #1 was highly impaired visually and had severe cognitive impairment. Resident #1 was dependent on staff for toilet hygiene, bathing and bed mobility and required the physical assistance of two people 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · Fcited before2024-06-24 · 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 — the official record, unedited, may be distressing

    Based on observation, staff interview, and review of the facility policy, the facility failed to seal and date opened food items in the freezer. This had to potential to affect all 19 residents residing in the facility. Findings include: Observation on 06/24/24 of the kitchen's freezer from 7:20 A.M. to 7:45 A.M. revealed an opened, unsealed, undated bag of Alaskan polluck, an opened, unsealed, undated bag of turkey sausage, an opened, unsealed, undated bag of seasoned beef patties. Interview on 06/24/24 at 7:25 A.M. with Dietary [NAME] #202 verified the finding. Interview on 06/24/24 at 1:26 P.M. with the Administrator stated all residents were getting food from the kitchen and there were no residents nothing by mouth. Review of the facility's Food Storage and Policy and Procedure, last revised 05/2013, revealed all food is to be stored, labeled and dated properly to assure stock rotation and prevent food illness. This deficiency represents non-compliance investigated under Complaint Number OH00154237.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 14 citations
  • Potential for harm · D2024-04-01 · tag F0620 — isolated
    Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.
    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 admissions documents, staff interview, and review of facility policy, the facility failed to ensure admission agreements were provided and signed timely for newly admitted residents. This affected three (#10, #11, and #12) of three residents reviewed for admissions. The facility census was 20. Finding Include: 1. Review of Resident #10's medical record revealed an admission date of 02/02/24 and a discharge date of 02/18/24. Diagnoses included sepsis, prostate cancer, type II diabetes, cognitive communication deficit, chronic kidney disease, hypertension, and acute respiratory infection. Review of Resident #10's admission agreement revealed Resident #10 was admitted to the facility on [DATE]. The admission agreement form contained the services the facility would provide, cost of services and payor sources, resident rights, bed hold notification, consent for ancillary services, and a consent to treat. Resident #10 was not provided his agreement for signature until…

    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 · D2024-01-22 · 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

    Based on record review and staff interview, the facility failed to follow physician orders to obtain daily weights to monitor for fluid overload. This affected two (#20 and #1) of three residents reviewed for daily weights. The facility census was 18. Findings include: 1. Review of the medical record for Resident #20 revealed an admission date of 10/12/23 and a discharge date of 12/18/23. Diagnosis included congestive heart failure (CHF). Review of the physician orders for Resident #20 revealed an order for daily weight and to notify the physician of a greater than two-pound weight gain in 24 hours, or greater than five pound weight gain in one week. Review of Resident' #20's Treatment Administration Record (TAR) for 10//23 revealed no daily weights were obtained for the following days: 10/17/23, 10/18/23, 1022/23, 10/24/23, 10/25/23, 10/27/23, 10/28/23, 10/29/23, 10/30/23, and 10/31/23. Review of the TAR for the month of 11/23 revealed revealed no daily weights were obtained for th following days: 11/02/23, 11/04/23, 11/05/23, 11/08/23, 11/09/23, 11/10/23, 11/12/23, and 11/13/23.…

    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 · Fcited before2022-08-25 · 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 ensure frozen food was stored in a safe and sanitary manner and ventilation ducts were kept clean. This had the potential to affect all 19 residents in the facility. The facility census was 19. Findings include: Observation on 08/22/22 at 9:33 A.M. of the walk in freezer found ice build up along the edge of the door, preventing the door from closing properly. Ice was built up on the inside of the door and covered the bars and racks on the shelving unit along with the boxes of food items on the shelves. The food items were not able to be identified due to the ice build up. Removal of some of the ice crystals from the front of the boxes found they contained breadsticks, pretzel buns, burritos, strawberry rhubarb pie, cherry pie and whipped topping. Also, boxes were found being stored on the floor containing chicken and tiramisu desserts. In addition, a large box of frozen peas was found to be open, uncovered, and unlabeled. Interview on 08/22/22 at 9:36 A.M. with Dietary Manager (DM) #419…

    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 · Fcited before2022-08-25 · tag F0880 — failed to prevent and control infections — widespread
    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, observation, staff interview, review of facility policy, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure facility staff wore proper Personal Protective Equipment (PPE) when in contact with a resident on Transmission-Based Precautions (TBP). This affected one (Resident #12) of two residents reviewed for TBP. The facility census was 19. Findings include: Medical record review revealed Resident #12 admitted to the facility on [DATE] with the diagnoses including, gangrene to right leg, right foot amputation, anxiety disorder, peripheral vascular disease, hypothyroidism, history of venous thrombosis and embolism, hypertension, chronic obstructive pulmonary disease, lymphedema, macular degeneration, and myocardial infarction. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #12 was alert, oriented, and able to make needs known. The resident was dependent on staff for the completion of 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-08-25 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and staff interview, the facility failed to ensure nail care and grooming was provided to a dependent resident. This affected one (Resident #7) of one resident reviewed for activities of daily living (ADLs). The facility census was 19. Findings include: Medical record review revealed Resident #7 admitted to the facility on [DATE] with the diagnoses including, hepatic failure, osteoarthritis, gastrostomy, dysphagia, dementia, protein calorie malnutrition, acute kidney failure, pancytopenia, glaucoma, depression, hypertension, and hypothyroidism. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #7 had severe cognitive impairment and was dependent on staff for the completion of ADLs. Review of the care plan dated 07/22/22 revealed Resident #7 had ADL self-care deficit and physical mobility deficit related to decrease in ability to perform ADLs, difficulty with mobility, and increase dependence for most ADLs. Interventions included the following:…

    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 · D2022-08-25 · 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 medical record review, observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure fall interventions were in place as care planned. This affected one (Resident #10) of two residents reviewed for falls. The facility census was 19. Findings include: Review of Resident #10's medical record revealed an admission date of 07/22/22. Diagnoses included Parkinson's disease, heart disease, alcohol abuse, depression, protein calorie malnutrition, cognitive communication deficit, and repeated falls. Review of Resident #10's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating Resident #10 was cognitively intact. Resident #10 required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Resident #10 displayed no behaviors during the review period. Resident #10 was noted to have had a fall prior to admission but none at the time of the review. Review of Resident #10'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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-08-25 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, medical record review and review of the medication administration policy, the facility failed to ensure two medications of 26 were provided within prescribed timeframe's, resulting in a medication error rate of 7.69 percent (%). This affected one (Resident #7) of four residents reviewed for medication administration. The facility census was 19. Findings include: Observation on 08/23/22 at 11:40 A.M. noted Registered Nurse (RN) #429 obtained Resident #7's medications from the medication cart to prepare them for gastrostomy tube (G-tube) administration. Medications included omeprazole suspension two milligrams (mg) per (/) one milliliter (ml) equaling 10 ml in a medication cup and Lorazepam 0.5 mg crushed and placed into a medication cup. RN #429 proceeded to Resident #7's room and administered the medications via G-tube. Interview with with RN #429 revealed the medications were ordered twice daily by the physician and were scheduled for 10:00 A.M. However, RN #429 was running behind. Review of Resident #7's physician orders revealed an order…

    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 · F2019-09-05 · tag F0803 — failed to meet residents' dietary needs — widespread
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and review of facility guidelines, the facility failed to ensure residents were provided the proper portion sizes for meals. This affected all 18 residents who received food from the kitchen. The facility census was 18. Findings Include: Observation 09/03/19 at 11:30 A.M. of tray line from the serving kitchen found Dietary Staff (DS) #205 using a #16 (two ounce) scoop for the scalloped potatoes and the pureed fish sticks. DS #205 was observed placing a single scoop of scalloped potatoes and a single scoop of pureed fish sticks on resident plates. DS #205 was observed placing varying amounts of French fries, soup, fish sticks, chicken salad, and mashed potatoes on residents' plates. Review of the spreadsheet being used by DS #205 revealed no portion sizes were present. Review of the resident meal tickets revealed the residents' order preferences were noted on the menu but no variation in amounts were noted. Interview on 09/03/19 at 11:38 A.M. with DS #205 revealed she chose the scoops and portion sizes for the meal items. DS #205 reported she…

    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 · Fcited before2019-09-05 · 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 guidelines, the facility failed to ensure opened food items were stored properly and food thermometers were cleaned between use. This had the potential to affect all 18 residents who received food from the kitchen. The facility census was 18. Findings include: Observation on 09/03/19 at 8:45 A.M. of the dry storage area of the kitchen found an opened, partially used, one gallon bottle of syrup on the dry storage shelf. The manufacturers label indicated, Refrigerate after opening. In addition, a dented can of navy beans was found in the dry storage room in line for use. Interview on 09/03/19 at 8:47 A.M. with Dietary Manager (DM) #200 verified the syrup was opened, partially used, and should have been stored in the refrigerator. DM #200 also verified the dented can of navy beans were in line for use. DM #200 removed and disposed of the syrup and beans. Observation on 09/03/19 at 11:30 A.M. of food temperatures being taken with Dietary Staff (DS) #205 found DS #205 used a regular white paper towel from the dispenser 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-09-05 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, resident interview, staff interview, and review of facility training, the facility failed to ensure residents choices on when to arise for the day were honored. This affected one (#2) of one resident reviewed for choices. The facility census was 18. Findings Include: Review of Resident #2's medical record revealed an admission date of 04/24/19. Diagnoses included atrial fibrillation, hypertension, anemia, lymphedema, moderate protein calorie malnutrition, chronic kidney disease, hypothyroidism, major depressive disorder, insomnia, anxiety disorder, gout, and muscle weakness. Review of the Minimum Data Set (MDS) assessment, dated 07/16/19, revealed Resident #2 was cognitively intact. Resident #2 required extensive assistance with bed mobility, locomotion, dressing, toilet use and personal hygiene. Resident #2 was dependent on staff for transfer. Resident #2 displayed the behavior of rejection of care one to three days out of the review period. Review of Resident #2's care plan, revised 06/14/19, revealed supports and interventions for self care deficit.…

    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 · D2019-09-05 · 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

    Based on record review, staff interview, and review of facility policy, the facility failed to issue timely notifications of the ending of skilled Medicare Part A services for two (#168 and #169) of three reviewed for liability notices. The facility identified four residents with Medicare as their primary payor source. The facility census was 18. Findings include: 1. Review of Resident #168 cut letter from Medicare part A services revealed the last day of covered services would end on 06/05/19. Resident #168's responsible party was informed on 06/04/19 of the resident's notice of Medicare non-coverage and their right to appeal. Interview on 09/05/19 at 10:24 A.M. with the Administrator verified Resident #168's last covered day for skilled services was on 06/05/19. The responsible party was notified on 06/04/19. 2. Review of Resident #169 cut letter from Medicare A skilled services for physical therapy and speech therapy (PT/ST) revealed the last covered day was 05/16/19. The resident's responsible party was informed via telephone on of the resident's last covered day and their right…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-09-05 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    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, staff interview, and medical record review, the facility failed to ensure individualized activity involvement was provided for one (#1) of twelve residents reviewed for the provision of ongoing activities. The facility census was 18. Findings include; Review of the medical record revealed Resident #1 admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, peripheral vascular disease, major depressive disorder, dementia, anxiety, osteoarthritis, pain, and age related osteoporosis. Review of the most current Minimum Data Set assessment, dated 08/13/19, identified the resident with severe cognitive impairment, the ability to understand and be understood, dependent on staff for the completion of activities of daily living including transfer and transport, and receiving hospice services. Review of activity plan of care revised, on 06/05/19, focused on the residents need for reminders and transportation to attend activities. Interventions included enjoying bingo, enjoys…

    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 before2019-09-05 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, medical record review and manufacturer recommendations for use instructions, the facility failed to ensure the administration of insulin included the proper dosage which resulted in a medication error rate of 6.25%. This affected two (#14, #5) of three residents reviewed for medication administration. The facility census was 18. Findings include;: 1. Observation on 09/04/19 at 7:22 A.M. noted Registered Nurse (RN) #101 to obtain a Toujeo SoloStar Solution Pen-injector 300 units (Insulin Glargine) per milliliter(ml) for administration to Resident #14. After entering the room and administering the resident's oral medications, RN#101 dialed the pen insulin indicator to 60 units, placed the injector tip to the pen, cleansed Resident #14's abdomen with a alcohol wipe and injected the 60 units of insulin. No prime of the pen was observed. RN#101 then discarded the soiled injector cap and placed a new injector cap on the pen followed by dialing a second dose of 60 units on the pen insulin indicator. Once RN#101 cleansed the abdomen the 60 units were…

    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 · Dcited before2019-09-05 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, medical record review and manufacturer recommendations for use instructions, the facility failed to ensure the administration of insulin included the proper dosage which resulted in a significant medication error for two (#14, #5) of three residents reviewed for medication administration. The facility census was 18. Findings include;: 1. Observation on 09/04/19 at 7:22 A.M. noted Registered Nurse (RN) #101 to obtain a Toujeo SoloStar Solution Pen-injector 300 units (Insulin Glargine) per milliliter(ml) for administration to Resident #14. After entering the room and administering the resident's oral medications, RN#101 dialed the pen insulin indicator to 60 units, placed the injector tip to the pen, cleansed Resident #14's abdomen with a alcohol wipe and injected the 60 units of insulin. No prime of the pen was observed. RN#101 then discarded the soiled injector cap and placed a new injector cap on the pen followed by dialing a second dose of 60 units on the pen insulin indicator. Once RN#101 cleansed the abdomen the 60 units were then injected…

    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

No federal fines in the current CMS record.

Part of a chain

This home belongs to OTTERBEIN SENIORLIFE — 20 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 53.2-0.2 vs chain
Health inspection 3 of 53.0≈ chain avg
Staffing 1 of 53.2-2.2 vs chain
Quality measures 5 of 54.1+0.9 vs chain
The other 19 homes this chain runs (chain average 3.2★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
OTTERBEIN LSC LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 01/01/2016
OTTERBEIN HOMEOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF100%since 12/01/2021
BARNES, DOROTHYIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 01/01/2022
BRYMER, GEORGEIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 01/01/2023
BUTCHKO, JOHNIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 01/01/2021
GLOSSER, HEIDIIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; TRUSTEE OF THE SNFsince 01/01/2020
HAHLER, BARBARAIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 01/01/2017
KOPP-MILLER, BARBARAIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 01/01/2022
PUCKETT, DAVIDIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 01/01/2025
RUCKSTUHL, JENNIFERIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 01/01/2025
SANDRETTO, MARKIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 01/01/2011
WEINER, ANDREWIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 01/01/2025
WIETRZYKOWSKI, KARA JOIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 01/01/2025
BARTLETT, VICTORIAIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 07/01/2010
GREEN, JAMESIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 11/21/2005
HAWKINS, RITAIndividualCORPORATE OFFICERsince 01/16/2009
MILLER, JASONIndividualCORPORATE OFFICERsince 08/04/2014
WILSON, JILLIndividualCORPORATE OFFICERsince 05/01/2009
FUNCTIONAL PATHWAYS OF TENNESSEE LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/07/2025
APP, LYNNIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/01/2021
BAYLIFF, BECKYIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/01/2021
BROWNSON, WILLIAMIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/01/2021
BURKE, DANIELIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/01/2021
COLEMAN, ROBERTIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/01/2021
FRALEY, RALPHIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/01/2021
HAZELBAKER, TOMASIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/01/2021
POLISETTY, SUDHEERIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/01/2021
SOLLER, BRIANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/03/2023
VONDERHAAR, STEVEIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/01/2021
BAKER, STEVEIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/07/2025
GALBUT, ABRAHAMIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/07/2025
GALBUT, DANIELIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/07/2025
GALBUT, DAVIDIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/07/2025
GALBUT, ERICIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/07/2025
GALBUT, ROBERTIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/07/2025
PARITZKY, JONATHANIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/07/2025
ROMBRO, DAVIDIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/07/2025
ZISEK, TODDIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/07/2025
POLARIS PHARMACY SERVICES OF OHIO LLCOrganizationADP OF THE SNFsince 12/01/2021

CMS files one row per role, so the 58 rows in the source record cover these 39 parties — each is shown once here with every role it holds. Nothing is omitted.

4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$7.4M
Net patient revenuemost recent cost report
-18.2%
Operating marginrevenue minus expenses
$589K
Related-party expense7% of expenses
Who pays — share of resident-days
Medicaid 12%Medicare 28%Other / private 60%

This home reported $589K 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 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$1,345per resident / day
operating cost
$40,896per month
≈ monthly operating cost
$1,138per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in OH

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 366148. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-01, 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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