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Vancrest-Upper Valley

3232 North County Road 25a, Troy, OH 45373 · Non profit - Corporation · 127 certified beds · (937) 440-7663 Medicare & Medicaid certified

Call the home — (937) 440-7663 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0607) — cited Aug 2019Resident-funds citation (F0569)Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation
Insights

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

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 a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has a citation for mishandling residents’ money or property (F0569)
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (32) — 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 (2/5)
  • its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

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

Worth a closer look. This home's quality-measure rating runs 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
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
3130 N County Road 25A · (937) 440-4900 · Call to confirm hours
Pharmacy
1801 W Main St · (937) 339-6335 · Call to confirm hours
Grocery
1801 W Main St · (937) 728-2244 · Call to confirm hours
Park
3147 N County Road 25A · (937) 335-6273 · Typically dawn to dusk
Place of worship
1580 N Dorset Lytle Rd · (937) 335-1313

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

Quality measures — how residents actually fare

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

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.

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

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 increased2.8%5.3%15.4%better than state — see note marked double-dagger below the table
Long-stay residents who lose too much weight4.8%6.2%5.4%better
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 infection0.7%0.4%2.0%worse than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms42.9%30.1%6.5%worse 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 injury6.7%3.2%3.3%worse
Long-stay residents whose ability to walk worsened3.3%6.1%16.1%better than state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication24.2%25.5%18.9%worse
Long-stay residents given the seasonal flu vaccine99.0%94.5%95.3%typical
Long-stay residents with pressure ulcers1.0%3.4%4.7%better
Long-stay residents with worsening bladder/bowel control12.5%21.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table6.5%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 vaccine88.8%75.6%79.4%better
Short-stay residents rehospitalized after admission16.7%24.9%22.6%better
Short-stay residents with an outpatient ER visit16.2%12.9%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.111.731.67better
Long-stay outpatient ER visits per 1,000 resident days1.601.801.80better

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.

52.9% 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 159 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

52.9%U.S. median 51.5%
Got home and stayed home
11.0%U.S. median 10.7%
Went back to hospital
81.6%U.S. median 56.6%
Met the expected recovery
0.50U.S. median 0.31
Therapy hours / resident / day
0.29hours / resident / day
Physical therapy
0.17hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 81.6% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 76 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 0.50 therapist hours per resident per day in 2026Q1 — more than 81% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 6% 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 SNF52.9%CMS range 46.7–60.351.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.0%CMS range 8.3–13.910.7%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 discharge81.6%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 discharge77.6%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 discharge71.0%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 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 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 stay1.0%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 worsened2.1%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 hospitalization7.3%CMS range 4.9–10.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.871.02Oct 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

0.53
RN hours/ resident / day
1.00
LPN hours/ resident / day
2.34
Aide hours/ resident / day
3.87
Total nurse hours/ resident / day
0.30
RN hoursweekends
40.9%
Total nursing turnover
30.0%
RN turnover

How full it usually is: this home is certified for 127 beds and averages 114.5 residents a day — about 90% occupied, or roughly 12 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.87 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.53 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.34 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 3.38 hrs/resident/day on weekends vs 4.07 on weekdays — 17% thinner on weekends. RN hours go from 0.63 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 41% 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

13
deficiencies at the latest standard inspection (2024-07-25)
11
at the previous standard inspection (2021-11-23)

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

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

Inspection deficiencies

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

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.

32 citations, most serious first. The 11 most serious are shown; the remaining 21 are one tap away and print in full.

  • Actual harm · G2019-08-22 · 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, medical record review, resident and staff interview, and review of the facility policy, the facility failed to ensure staff provided ongoing monitoring of a resident's left heel pressure ulcer and failed to notify the physician when the wound deteriorated/began draining. This resulted in Actual Harm to one resident (#75) when facility staff did not provide ongoing monitoring of Resident #75's left heel pressure ulcer including measuring/staging the wound, did not notify the physician when the wound began to drain and Resident #75's left heel ulcer subsequently deteriorated into an unstageable pressure ulcer (the area could not be staged due to presence of slough and/or eschar). Additionally, the facility failed to ensure preventative measures were in place and treatments were completed as ordered by the physician for a second resident's (#112) pressure ulcer, which placed the resident at risk for potential harm. This affected two (#75 and #112) of six residents reviewed for pressure ulcers.…

    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 · D2024-07-25 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, resident representative interview, and staff interview, the facility failed to notify resident representative of new order for antibiotic and reason for the use of the medication. This affected one (#1) resident out of two residents reviewed for antibiotic use. The facility census was 99. Findings include: Review of the medical record for Resident #1 revealed an admission date of 03/08/13. Diagnoses included quadriplegia, chronic respiratory failure, anoxic brain damage, persistent vegetative state, and tracheostomy. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/30/24, revealed Resident #1 was in a persistent vegetative state. Review of the physician order dated 07/18/24 revealed an order for amoxicillin-pot Clavulanate (Augmentin) 875-125 (antibiotic) milligram (mg) one tablet via gastrostomy (g-tube) every 12 hours for bacterial infection. Review of the physician note, dated 07/18/24, revealed Resident #1 was seen due to redness and swelling of the right jaw. Resident #1's examination was positive for swollen glands and was…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-25 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    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 and resident interviews, and policy review, the facility failed to make prompt efforts to resolve a resident's grievance related to missing property. This affected one (#83) of three residents reviewed for missing property. The facility census was 99. Findings include: Review of the medical record for Resident #83 revealed an admission date of 10/26/22. Diagnoses included diabetes mellitus with diabetic peripheral angiopathy, peripheral vascular disease, and congestive heart failure. Resident #83 was admitted to the hospital on [DATE] and returned to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #83 was cognitively intact. Interview on 07/22/24 at 9:26 A.M. with Resident #83 stated she was hospitalized in early June 2024 and while she was at the hospital, her roommate at the facility had discharged . Resident #83 stated her roommate's family packed all the roommate's belongings and took the items home.…

    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 · D2024-07-25 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    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, policy review, and review of the Resident Assessment Instrument (RAI) manual 3.0, the facility failed to ensure a significant change Minimum Data Set (MDS) assessment was completed timely after a resident experienced a significant change of condition. This affected one (#83) of seven residents reviewed for significant change in condition. The facility census was 99. Findings include: Review of the medical record for Resident #83 revealed an admission date of 10/26/22. Diagnoses included nondisplaced intertrochanteric fracture of right femur and right clavicle, diabetes mellitus with diabetic peripheral angiopathy, peripheral vascular disease, and congestive heart failure. Resident #83 was admitted to the hospital on [DATE] and returned to the facility on [DATE]. Review of the Medicare five-day MDS assessment, dated 04/14/24, revealed Resident #83 was cognitively intact and required supervision or touching assistance with toilet hygiene, transfers, and toilet…

    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 · D2024-07-25 · 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 — the official record, unedited, 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 a resident had a care plan in place for his behavior with wandering and residing on a secure unit. This affected one (Resident #20) of 27 residents reviewed for care plans. The facility census was 99. Findings include: Review of the medical record of Resident #20 revealed an admission dated of 05/13/24. Diagnoses included dementia with behavioral disturbance and Alzheimer's disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was at a risk for wandering. Review of the form Wandering Risk Assessment dated 06/18/24 revealed Resident #20 was at a high risk for wandering. Review of Resident #20's care plan revealed there was no focus area of wandering or residing on a secure unit. Interview on 07/24/24 at 3:27 P.M. with Licensed Practical Nurse (LPN) #327 verified Resident #20's care plan contained no focus or interventions for wandering or residing in a secure unit.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-25 · 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 observation, policy review, record review, and staff interview, the facility failed to follow proper mechanical lift protocols during a resident's transfer from the bed to a wheelchair. This affected one resident (#47) of three residents reviewed for transfers with lifts. The facility census was 99. Findings include: Record review for Resident #47 revealed the resident was originally admitted to the facility on [DATE]. Diagnoses for Resident #47 included cerebral infarction, diabetes mellitus type two, obesity, and heart disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 had impaired cognition and was dependent on staff for transfers. Review of Resident #47's care plans dated 05/01/17 revealed a focus for falls and injuries relating to mobility. Resident #47 utilized a lift for transfers. Interventions included using a Hoyer lift for all transfers with two staff members. Continuous observation on 07/23/24 from 9:16 A.M. to 9:30 A.M. revealed State…

    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 · D2024-07-25 · 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

    Based on medical record review and staff interview, the facility failed to ensure a resident with an indwelling catheter had a valid medical justification for the use. This affected one (Resident #50) of three residents reviewed for indwelling catheter. The facility census was 99. Findings include: Review of the medical record for Resident #50 revealed an admission date of 05/27/24. Diagnoses included right above the knee amputation (AKA), atrial fibrillation, diabetes mellitus, hypertension, peripheral vascular disease, and anemia. Review of the admission Minimum Data Set (MDS) assessment revealed Resident #50 had moderate cognitive impairment and was dependent upon staff for toileting, and had an indwelling catheter. Review of Resident #50's physician order dated 05/28/24 revealed an order for an indwelling urinary catheter 16 French with 10 milliliter (ml) balloon to continuous drainage. There was diagnosis for the use of the catheter on the physician order. Review of the bladder and bowel assessment, dated 06/22/24, revealed Resident #50 had a history of bladder continence, used…

    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 · D2024-07-25 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the facility policy, observation, and staff interview the facility failed to assess the need for bed rails on a resident's bed. This affected one (Resident #21) of three residents reviewed for bed rails. The facility census was 99. Findings include: Record review for Resident #21 revealed the resident was admitted to the facility on [DATE] and started to receive hospice services on 10/05/23. Diagnoses for Resident #21 included Alzheimer's disease, dementia, weakness, kidney failure, and heart disease. Review of admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had impaired cognition, was not using bed rails, and was receiving hospice services. Review of Resident #21's documentation revealed as of 09/2014 the resident's daughter was medical Power of Attorney (POA). The census record revealed Resident #21's daughter was designated as the POA and emergency contact family representative. Review of a consent form dated 10/05/23 revealed half partial rails…

    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 · D2024-07-25 · 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 record review and staff interview, the facility failed to ensure pharmacy recommendations were responded to in a timely manner. This affected one (Resident #23) of five residents reviewed for unnecessary medication use. The facility census was 99. Findings include: Record review for Resident #23 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #23 include Parkinson's disease, depression, anxiety, vascular dementia, and unspecified psychosis. Review of Resident #23's Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition, no behaviors, and was receiving an antipsychotic medication. Review of Resident #23's care plans dated 10/23/13 revealed a focus for complications of vitamin deficiency. Interventions include administer medications per order, monitor lab results and report abnormalities to physician, and schedule/arrange for resident to attend diagnostic testing as ordered. Review of the pharmacy recommendation 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-25 · 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

    Based on medical record review, outside provider interview, and physician interview, the facility failed to ensure residents were free from unnecessary medication use. This affected one (Resident #38) of five residents reviewed for unnecessary medication use. The facility census was 99. Findings include: Review of the medical record of Resident #38 revealed an admission date of 01/20/21. Diagnoses include acquired absence of kidney and renal cancer. Review of the medical record revealed Resident #38 had been diagnosed with a urinary tract infection (UTI) on 10/02/23, 02/25/24, and 03/19/24. Review of the physician orders dated 04/03/24 revealed an order for Macrodantin macrocrystal 50 milligrams one time daily for prophylactic/indefinitely. Review of a outside practitioners report dated 05/16/24 revealed Resident #38 was seen for a follow-up regarding a UTI. The report indicated Resident #38 was currently experiencing nocturnal one time per night, but was not experiencing hematuria, dysuria, urinary frequency, fever, chills, nausea, vomiting or urgency. The form indicated doing…

    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 · D2024-07-25 · 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, medical record review, staff interview, review of Medscape guidance, review of the insulin pen quick reference guide, and policy review, the facility failed to prime an insulin pen per manufacturer instructions prior to administration, resulting in a significant medication error. This affected one (#83) of three residents observed for medication administration. The facility census was 99. Findings include: Review of the medical record for Resident #83 revealed an admission date of 10/26/22. Diagnosis included diabetes mellitus (DM). Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/13/24, revealed Resident #83 was cognitively intact and received insulin. Review of the physician order dated 07/08/24 for Humalog Kwikpen 100 unit per milliliter (ml) solution pen injector, inject 10 units of insulin subcutaneous (SQ) before meals related to DM. Observation on 07/23/24 at 7:45 A.M. revealed Licensed Practical Nurse (LPN) #248 prepared Humalog kwikpen for Resident #83. LPN #248 attached the needle to injector pen and set the dose on the pen to 10…

    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
Show the remaining 21 citations
  • Potential for harm · Dcited before2024-07-25 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, resident and staff interviews, medical record review, and policy review, the facility failed to ensure medications were consumed at the time of administration and not left at the resident's bed side unsupervised. This affected one (#302) resident out of the three residents reviewed for medication administration. The facility census was 99. Findings include: Review of the medical record for Resident #302 revealed an admission date of 07/17/24. Diagnoses included aftercare following joint replacement, acquired absence of right hip joint, anemia, anxiety, and hypertension. Review of the admission assessment, dated 07/17/24, revealed Resident #302 was alert and oriented to person, place, time, and situation. Review of the physician orders dated 07/23/24 to be administered at 8:00 A.M. revealed celecoxib (anti-inflammatory drug) 200 milligram (mg) one tablet by mouth, cholecalciferol (supplement) 1,000 units one tablet by mouth, Cymbalta (anti-depressant) 60 mg one tablet by mouth, folic acid (vitamin) one mg one tablet by mouth, leflunomide (treats rheumatoid…

    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 · D2024-07-25 · 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 observation, staff interview, record review and review of the facility policy the facility failed to follow isolation protocols while providing care to residents. This affected one (Resident #47) of five residents reviewed for isolation precautions. The facility census was 99. Findings include: Record review for Resident #47 revealed the resident was originally admitted to the facility on [DATE]. Diagnoses for Resident #47 included cerebral infarction, diabetes type two mellitus, and heart disease. Review of the care plan dated 08/02/22 revealed Resident #47 was at risk for infection. Interventions included isolation protocols per policy. There was also a focus for wounds and skin breakdown. Interventions included to follow isolation protocols per policy. Review of the facility's infection control list dated 07/22/24 for all residents requiring isolation protocols, revealed Resident #47 was on the list for a wound. Observation on 07/22/24 at 9:00 A.M. of Resident #47's hallway revealed hanging on the…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-11-23 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff and resident interviews, and policy review, the facility failed to ensure a resident had a call light within reach at all times. This affected one (#10) of 32 residents observed for call light use. The facility census was 109. Findings include: Review of Resident #10's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, quadriplegia, obesity, and diabetes mellitus. Review of the Minimum Data Set (MDS) assessment, dated 11/11/21, revealed Resident #10 was cognitively intact and he was totally dependent on one to two staff members for all activities of daily living. Review of the plan of care, dated 07/07/21, revealed Resident #10 had a muscular skeletal disorder and limited range of motion. The interventions included to be sure his call light was within reach and respond promptly to all requests for assistance. Observation on 11/21/21 at 10:20 A.M. revealed Resident #10's soft touch call light cord…

    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 · Dcited before2021-11-23 · tag F0569 — isolated
    Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, review of the facility's policy, and staff interview, the facility failed to notify the resident and resident's representative when the resident's amount exceeded the resource limit. This affected one (Resident #84) of five residents reviewed for personal trust fund accounts. The facility identified 70 residents who have personal trust fund accounts. The facility census was 109. Findings include: Review of Resident #84's medical record revealed an admission date of 01/29/16 with diagnoses which included spastic hemiplegia, cerebral vascular accident, diabetes, and depression. Review of the Minimum Data Set (MDS) assessment, dated 10/02/21, revealed Resident #84 had impaired cognitive skills. Review of Resident #84's profile revealed the resident's brother was the resident's responsible party and emergency contact. Interview on 11/22/21 at 7:45 A.M. with the Business Office Manager (BOM) #140 revealed Resident #84's current balance was $4,593.21. The BOM #140 identified the resident's amount included a stimulus check of $600 received in January 2021 and a…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-11-23 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, review of the facility's policy, and staff interviews, the facility failed to ensure the resident's Ohio Comfort Care Do Not Resuscitate (DNR) form was accurately completed. This affected one (Resident #38) of three residents reviewed for advanced directives. The facility census was 109. Findings include: Review of Resident #38's medical record revealed an admission date of 12/16/20. Diagnoses included pneumonia, morbid obesity, and cerebrovascular disease. Review of the Minimum Data Set (MDS) assessment, dated 11/05/21, revealed Resident #38 had impaired cognition and the resident required extensive one-person assistance for bed mobility, dressing, toileting, and personal hygiene. Review of Resident #38's Ohio Comfort Care Do Not Resuscitate (DNR) order form, dated 12/23/20, revealed the form was completed by the Certified Nurse Practitioner (CNP) #450. The form included a statement which read; REQUIRED for APRN (advanced practice nurse) or PA (physician assistants): Name of supervising physician (PA) or collaborating physician (APRN) for this…

    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 · D2021-11-23 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident and staff interviews, and policy review, the facility failed to notify the physician of significant weight gain for one resident (#60) of five residents reviewed for alteration in weight. The facility identified nine residents with unplanned significant weight gain or loss. The facility census was 109. Findings include: Review of Resident #60's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including non alcoholic liver cirrhosis, diabetes mellitus, and psoriasis. Review of the annual Minimum Data Set (MDS) assessment, dated 10/12/21, revealed Resident #60 had no cognitive deficits. Review of the History and Physical, dated 11/17/20 (prior to admission on [DATE]) revealed on 05/04/20, the resident experienced elevated liver enzymes . On 10/12/20, the resident was diagnosed with lactic acidemia and liver cirrhosis due to non alcoholic fatty liver disease. Review of the plan of care, dated 07/12/21, revealed the goals were 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-11-23 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff and resident interview, and policy review, the facility failed to ensure care conferences were completed quarterly for Resident #50. The facility also failed to ensure the care plans were revised quarterly for Resident #60. This affected two (#50 and #60) out of 22 residents reviewed for care plans during the annual survey. Findings include: 1. Medical record review for Resident #50 revealed an admission date of 09/21/17. Diagnoses included bipolar disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/19/21, revealed Resident #50 was cognitively intact. Review of the care conferences, dated 01/13/21, revealed this was the last care conference provided to Resident #50. Interview with Resident #50 on 11/21/21 at 10:30 A.M. revealed she had not received a care conference in a long time. Interview with Licensed Social Worker (LSW) #204 on 11/23/21 at 9:31 A.M. confirmed she was only doing quarterly care conference if the residents and the families…

    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 · Dcited before2021-11-23 · 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 medical record review, staff interview, and policy review, the facility failed to ensure weights were obtained and documented as ordered for Resident #85. This affected one (#85) of two residents reviewed for edema. The facility census was 109. Findings include: Review of Resident #85's medical record revealed an admission date of 11/20/19. Diagnosis included cerebrovascular disease, hypertension, atherosclerotic heart disease of native coronary artery without angina pectoris, paroxysmal atrial fibrillation, and chronic kidney disease. Review of the plan of care, dated 06/24/21, revealed Resident #85 was at risk for alteration in cardiac function related to coronary artery disease, cardiac arrhythmia, hypertension, and history of myocardial infarction. Interventions included to assess for edema and report any problems to the physician. Review of the annual Minimum Data Set (MDS) assessment, dated 10/21/21, revealed Resident #85 received diuretics. Review of the physician orders, dated 10/20/21, revealed an order for weekly weights every Wednesday for edema. Review of 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 · D2021-11-23 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for 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 medical record review, observations, resident and staff interviews, the facility failed to implement a palm protector to prevent further decline in range of motion for one resident (#49). This affected one (#49) of three residents reviewed for limited range of motion. The facility identified 27 residents with contractures. The facility census was 109. Findings include: Review of Resident #49's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia, contracture of multiple sites and Parkinson's disease. Review of the annual Minimum Data Set (MDS) assessment, dated 07/06/21, revealed Resident #49 had moderate cognitive deficits. Resident #49 required extensive assistance one person for personal hygiene and dressing. He had no rejection of care. Review of the plan of care, dated 07/09/21, revealed Resident #49 had Parkinson's disease. The goal was for Resident #49 to remain free of further signs and symptoms of discomfort or complications 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
  • Potential for harm · D2021-11-23 · 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, staff interview, and policy review, the facility failed to ensure an anti-anxiety medication was addressed every 14 days. This affected one (#88) of five residents reviewed during the annual survey for unnecessary medications. The facility census was 109. Findings include: Medical record review for Resident #88 revealed an admission date of 02/22/21. Diagnoses included anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/05/21, revealed Resident #88 was severely cognitively impaired. Review of the physician orders, dated 10/17/21, revealed Lorazepam 0.5 milligram (mg) to give one tablet every six hours as needed (PRN) for anxiety. There was no physician order to extend Lorazepam past the 14 days from 10/17/21 and there was not a specified duration of the medication noted by the prescriber. Lorazepam was discontinued on 11/20/21. Review of the Note to Attending Physician recommendation from the pharmacy, dated 10/28/21, revealed Resident #88 was receiving a PRN psychotic therapy Lorazepam and per the Center of Medicare…

    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 before2021-11-23 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observation, review of the facility policy, and staff interview, the facility failed to ensure stored medications were within expiration dates. This affected one of four medication carts reviewed for medication storage. The facility had a total of six medication carts. This affected two residents (#24 and #41) who had insulin stored in the medication cart. The facility census was 109. Findings include: Observation of the facility's South medication cart on 11/22/21 at 3:48 P.M. with Licensed Practical Nurse (LPN) #243 revealed a vial of Lantus Insulin Glargine Injection 100 units/milliliter (units/ml) for Resident #41 with an open date 09/25/21. Review of the pharmacy label on the vial revealed instructions to discard 28 days after opening. Observation of Lantus Insulin Glargine Injection Flexpen 100 units/ml for Resident #41 revealed an open date of 09/19/21. Observation of Novolin 70/30 Human Insulin Isophane Suspension Flexpen for Resident #24 revealed an open date 10/09/21. Review of the pharmacy label to discard 28 days after opening. These findings 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 before2021-11-23 · tag F0770 — failed to provide lab services — isolated
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    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 obtain laboratory tests as ordered by the physician for one resident (#60) of six residents reviewed for laboratory results. The facility census was 109. Findings include: Review of Resident #60's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including non alcoholic liver cirrhosis and psoriasis. Review of the annual Minimum Data Set (MDS) assessment, dated 10/12/21, revealed Resident #60 had no cognitive deficits. Review of the physician progress note from Gastroenterologist #410, dated 07/22/21, revealed Resident #60 was seen in the office for alternating constipation and diarrhea and cirrhosis of the liver. The plan stated to obtain an ultrasound of the liver, laboratory studies including complete blood count (CBC), comprehensive metabolic panel (CMP), ammonia level and pro-time (PT) in three months and follow up with the Gastroenterologist for a 30-minute follow up visit. 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-11-23 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
    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 record review, observation, review of the facility's policy, and staff interviews, the facility failed to ensure resident care equipment was maintained in a clean condition. This affected one (Resident #26) of 32 residents observed for clean environment. The facility census was 109. Findings include: Medical review for Resident #26 revealed admission date 03/08/13 and readmission date 05/16/21. Diagnoses included anoxic brain damage, dysphagia, aphasia, gastrostomy, and tracheostomy. Review of the annual Minimum Data Set (MDS) assessment, dated 09/10/21, revealed Resident #26 required tube feed nutrition and tracheostomy care. Observation on 11/21/21 at 2:18 P.M. revealed there was tube feed dried on Resident #26's platform for the tracheostomy mist machine. A thick layer of dried tube feed covered the entire back ledge of the platform. A housekeeper was cleaning the room and had sprayed a cleaner on the dried tube feed spots on the floor. The housekeeper stated she did not clean the tube feed pump, stand, platform, or the tracheostomy mist machine. Interview on on 11/21/21…

    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 · Ecited before2019-08-22 · tag F0770 — failed to provide lab services — pattern
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility policy and staff interview, the facility failed to ensure laboratory values were obtained per physcian orders and/or the results provided to the facility timely for four (Resident #3, #54, #84 and #112) of five residents reviewed for unnecessary medications. The facility census was 120. Findings include: 1. Review of Resident #3's medical record revealed an admission date of 09/14/17. Diagnoses included coronary artery disease, chronic atrial fibrillation and hypertension. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 08/01/19, revealed Resident #3 was cognitively impaired and indicated the resident received an anticoagulant medication daily. Review of the resident's care plan, dated 09/14/17, revealed the resident was at risk for bleeding related to Coumadin (blood thinning medication). Interventions included to monitor labs as ordered and report abnormal findings to physician. Review of the physician orders for April 2019 and May 2019 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-08-22 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, resident interview and staff interview, the facility failed to ensure the dignity of residents with indwelling catheters was upheld. This affected two (Resident #23 and #323) of two residents reviewed for catheters. The facility identified five residents with catheters. The facility census was 120. Findings include: 1. Review of the medical record for Resident #23 revealed the resident was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, urinary tract infection, obesity, quadriplegia, anxiety, depression and disorder of bladder. Review of the annual Minimum Data Set (MDS) assessment, dated 03/01/19, revealed Resident #23 had intact cognition and had an indwelling urinary catheter. Observations on 08/20/19 at 8:00 A.M., 08/20/19 at 9:13 A.M. and 08/21/19 at 8:56 A.M. revealed Resident #23's room door was open. Resident #23's catheter bag was hanging on the bed frame uncovered and was visible from the hallway in front of the resident's room. Interview…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-08-22 · tag F0569 — isolated
    Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
    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 resident accounts, staff interview and review of facility policy, the facility failed to notify Medicaid Residents/Representatives, when their account was $200.00 less than the Supplemental Security Income (SSI) limit of $2,250, and the facility failed to return a resident funds to the State after his death. This affected four (Resident #27, #54, #101 and #177) of five residents accounts reviewed. The facility census was 120. Findings include: 1. Review of Resident #27's personal funds account revealed a copy of a letter of notification, dated [DATE], sent to the resident's representative that the residents funds account balance was $4905.00. On [DATE], review of the residents account balance revealed a balance of $5195.93. 2. Review of Resident #54's personal funds account revealed a copy of a letter of notification, dated [DATE], sent to the resident's representative that the residents funds account balance was $2490.93. On [DATE], review of the residents account balance revealed a balance…

    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 · Dcited before2019-08-22 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility policy and staff interview, the facility failed to ensure resident's advance directives were accurate. This affected two (#22 and #112) of 32 residents reviewed for advance directives. The facility census was 120. Findings include: 1. Review of Resident #112's medical record revealed an admission date of [DATE]. Medical diagnoses included abnormal levels of serum enzymes, chronic atrial fibrillation, chronic obstructive pulmonary disease, dysphagia, hypertension, and hypothyroidism. Review of the resident's Minimum Data Set (MDS) assessment, dated [DATE], revealed no impairment in cognition. Review of the resident's electronic medical record physician's orders and face sheet revealed no evidence of the resident's code status. Review of the resident's paper chart revealed no physician's orders to clarify the resident's code status. The front of the resident's chart contained a full code form with a blank space for resident/representative signature and the nurse…

    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 · Dcited before2019-08-22 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and resident and staff interview, the facility failed to monitor an open wound on a resident. This affected one (Resident #22) of three residents reviewed for skin conditions. The facility census was 120. Findings include. Review of the medical record for Resident #22 revealed the resident was re-admitted to the facility on [DATE] with an original admission of 10/08/18. Diagnoses included weakness, sepsis, atrial fibrillation, muscle weakness, depression, lymphoma, arthritis and dementia. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 02/06/19, revealed the resident had intact cognition and was at risk for skin breakdown. Review of the care plans, dated 10/08/18 and revised on 04/25/19, revealed a focus for skin breakdown. One intervention for the focus included monitor left lower leg skin integrity for breakdown. Review of the weekly skin assessments, dated 06/04/19, revealed the resident had intact skin and no open areas to bilateral arms were resolved.…

    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 · D2019-08-22 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of a facility policy, the facility failed to ensure pneumococcal vaccinations were offered. This affected one (Resident #92) of five residents reviewed for pneumococcal vaccinations. The facility census was 120. Findings include: Review of Resident #92's medical record revealed she was admitted to the facility on [DATE]. There was no evidence in the medical record the resident was screened for the necessity of a pneumococcal vaccination upon admission or annually thereafter. Interview with the Director of Nursing on 08/20/19 at 3:00 P.M. verified Resident #92 did not have a pneumonia consent completed upon admission or annually thereafter. She verified the facility had no documentation the resident had received a pneumonia vaccine. Review of the facility policy titled Pneumococcal Policy, revised in 04/2019, revealed residents admitted to the facility will be given the opportunity to receive the pneumococcal vaccine per physician order. The nurse will…

    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
  • No harm found · B2024-07-25 · tag F0582 — pattern
    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 record review and staff interview, the facility failed to provide the residents with the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) and the Notice of Medicare Provider Non-Coverage (NOMNC). This affected two (#58 and #91) of three residents reviewed for beneficiary notices. The facility census was 99. Findings include: 1. Review of the medical record of Resident #58 revealed an admission date of 02/08/24. Review of the SNF ABN for Resident #58 revealed the last covered day of Part A service was 03/11/24. Review of the NOMNC indicated the service will end on 03/11/24. A handwritten note by Quality Assurance (QA) #328 stated the daughter was notified of LCD (last covered day) for skilled care to end on 03/11/24 and the right to appeal Livanta (third party auditor to review documentation to cover Medicare) at [PHONE NUMBER]. The note was signed on 03/06/24. The form was not signed by Resident #58 or family. Interview on 07/24/24 at 9:44 A.M. with QA #328 revealed she had…

    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
  • No harm found · C2019-08-22 · tag F0607 — failed to have anti-abuse policies — widespread
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of personnel files, staff interview and review of a facility policy, the facility failed to implement their abuse policy by ensuring reference checks were completed upon hire. This affected seven of seven newly hired personnel files reviewed. This had the potential to affect all 120 residents residing in the facility. Findings include: Review of the following personnel files revealed no evidence of reference checks completed prior to hire for the following staff members: • The Director of Nursing was hired on 07/29/19 • The Administrator was hired on 03/18/19 • Registered Nurse (RN) #190 was hired on 07/10/19 • Director of Sales #191 was hired on 06/18/19 • Social Services Director #189 was hired on 05/24/19 • State Tested Nursing Aide (STNA) #191 was hired on 07/11/19 • STNA #192 was hired on 08/05/19 Interview with Staff Development Nurse #178 on 08/22/19 at 3:29 P.M. verified the facility did not have reference checks for any of the new employees. She stated the staff person who performed reference checks was no longer employed and the facility was unable 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has plan 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 VANCREST HEALTH CARE CENTERS — 13 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 4 of 54.0≈ chain avg
Health inspection 3 of 53.6-0.6 vs chain
Staffing 2 of 52.7-0.7 vs chain
Quality measures 5 of 54.8+0.2 vs chain
The other 12 homes this chain runs (chain average 4.0★, 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
BAGLEY, JONIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICERNO PERCENTAGE PROVIDEDsince 12/30/2024
MCCLEERY, MARKIndividual5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/30/2024
MYERS, MARKIndividual5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/30/2024
WHITE, CLAIREIndividual5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/30/2024
WHITE, MARKIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLNO PERCENTAGE PROVIDEDsince 12/30/2024
WHITE, NICOLAUSIndividual5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/30/2024
WHITE, SCOTTIndividual5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/30/2024
SILALAHI, EDGARIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/30/2024
STEWART, SHANEIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/30/2024
TROY HEALTH FACILITIES, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/30/2024
VANCREST MANAGEMENT CORP.OrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/30/2024
ALLEN, BETTYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/30/2024
CONTENTO, ROBERTIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/30/2024
FUELLING, ELIZABETHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/30/2024
MADIREDDY, NAGAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/30/2024
PARKER, KATHYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/30/2024
POTTENGER, JULIAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/30/2024
RUDASILL, MARKIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/30/2024
SUTHERLAND, CIERRAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/30/2024
AQUILA INITIATIVE INCOrganizationADP OF THE SNFsince 12/30/2024
BASHORE REINECK STOLLER & WATERMAN INCOrganizationADP OF THE SNFsince 12/30/2024
HOWARD, WERSHBALE & COOrganizationADP OF THE SNFsince 12/30/2024
THERAPY SOLUTIONSOrganizationADP OF THE SNFsince 04/01/2025
TWOMAGNETS LLCOrganizationADP OF THE SNFsince 12/30/2024
UVMC NURSING CARE, INCOrganizationADP OF THE SNFsince 12/27/1989
VERACITY RESOURCING AND SERVICES LLCOrganizationADP OF THE SNFsince 12/30/2024

CMS files one row per role, so the 43 rows in the source record cover these 26 parties — each is shown once here with every role it holds. Nothing is omitted.

9 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.

$12.1M
Net patient revenuemost recent cost report
-1.0%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 59%Medicare 11%Other / private 30%

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

$307per resident / day
operating cost
$9,337per month
≈ monthly operating cost
$304per 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 365735. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-07-25, 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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