Canterbury Of Twinsburg
9928 Vail Drive, Twinsburg, OH 44087 · For profit - Limited Liability company · 50 certified beds · (330) 405-6040 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Feb 2024
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (28) — 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
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's 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
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 11.7% | 5.3% | 15.4% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 8.3% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.2% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.2% | 0.4% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 2.6% | 30.1% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 0.6% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 13.7% | 6.1% | 16.1% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 14.6% | 25.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.1% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 20.4% | 21.4% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 7.9% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.5% | 1.2% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 97.7% | 75.6% | 79.4% | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ 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.
55.6% 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 27 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.41 therapist hours per resident per day in 2026Q1 — more than 71% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 13% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 55.6%CMS range 36.9–73.5 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.6%CMS range 7.1–16.4 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.04 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 50 beds and averages 46.9 residents a day — about 94% occupied, or roughly 3 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.10 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.92 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.68 is at or above 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 4.54 hrs/resident/day on weekends vs 5.33 on weekdays — 15% thinner on weekends. RN hours go from 1.16 to 0.35 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 50% 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
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
28 citations, most serious first. The 12 most serious are shown; the remaining 16 are one tap away and print in full.
- Actual harm · Gcited before2025-06-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, staff and resident interviews, review of video footage, review of facility investigation, and facility policy review, the facility failed to ensure residents were safely transferred using a Hoyer lift. Actual Harm occurred on 05/08/25 at approximately 2:15 P.M. when Hospice Nurse Aide (HNA) #869 completed a Hoyer lift (a type of mechanical lift used to safely transfer individuals with limited mobility from one surface to another) transfer of Resident #21 without the assistance of a second person, resulting in Resident #21's arm becoming fractured. Resident #21 required an x-ray examination which revealed a displaced (a bone fracture where the broken bone fragments are no longer in normal alignment), separated (the bone is broken in two or more places creating a separate segment of bone between breaks), overriding (the broken ends of a bone overlap causing shortening)…
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.
- Actual harm · G2022-06-28 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of facility policy the facility failed to ensure Resident #36 did not develop avoidable pressure injuries of the knees. Actual harm occurred when Resident #36 developed a right knee deep tissue injury (Persistent non-blanchable deep red, maroon or purple discoloration intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue.) and a left knee Stage 3 pressure ulcer (Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and rolled wound edges are often present. Slough and/or eschar may be visible but do not obscure the depth of tissue loss.). This affected one resident (Resident #36) of three residents reviewed for pressure injuries. The census was 49. Findings include: Review of Resident #36's medical record revealed an admission date of 07/30/21 and diagnoses including senile degeneration of the brain, multiple fracture…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-14 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably 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 record review and interview the facility failed to ensure Resident #27's call light was responded to in a reasonable amount of time. This affected one resident (#27) of three residents reviewed for call light response times. The facility census was 37. Findings include: Review of the medical record for Resident #27 revealed an admission date of 06/09/24 with diagnoses including difficulty walking, anxiety, obsessive compulsive disorder, and urinary incontinence. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition and required partial to moderate assistance from staff for toileting hygiene and substantial to maximum assistance for transfers. The assessment also indicated Resident #27 was frequently incontinent of bowel and bladder. Review of the alarm event report dated 11/07/24 through 11/14/24 revealed Resident #27's call light was pulled at 4:00 P.M. and cleared at 4:26 P.M. with the response time being 25 minutes and 35 seconds. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to prevent a fall for Resident #8 who was completely dependent on staff for fall prevention. This affected one resident (Resident #8) of three residents reviewed for falls. The facility census was 37. Findings include: Record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including persistent vegetative state, brain damage, lack of coordination, abnormal posture, and dementia. Review of physician order dated 12/05/19 revealed Resident #8's head of bed was to be up at a 30 degree angle. Review of physician orders dated 11/15/23 revealed Resident #8 had a camera in the room at the request of the Power of Attorney (POA). Review of a physician order dated 11/28/23 revealed Resident #8 was to be out of bed at 11 A.M. and back in bed at 5:00 P.M. Review of a physician order dated 08/05/24 revealed Resident #8 was a hospice resident due to anoxic brain damage. Review of the Minimum Data Set (MDS) 3.0 assessment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-14 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of the facility policy the facility failed to ensure appropriate infection control practices were implemented when Resident #10 was provided incontinence care. This affected one resident (Resident #10) of 37 residents observed for infection control. The facility identified 11 residents (Resident's #10, #12, #13, #14, #15, #17, #18, #25, #26, #30 and #40) as incontinent and residing on the nursing unit of Resident #10. The facility census was 37. Findings include: Review of Resident #10's medical record revealed an admission date of 06/23/23 and diagnoses included unilateral primary osteoarthritis right hip, muscle weakness, and chronic kidney disease. Review of Resident #10's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #10 was cognitively intact. Resident #10 required substantial to maximal assistance with toileting hygiene and bathing. Resident #10 was always incontinent of urine and frequently incontinent of bowel.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-14 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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
Based on staff interview, review of facility policy, review of the employee handbook, and review of photographs taken on a staff member's cell phone, the facility failed to ensure Resident #5 was treated with dignity and respect at all times. This affected one resident (#5) of four residents reviewed for dignity. The facility census was 41. Findings include: Review of the medical record for Resident #5 revealed an admission date of 05/11/21 with diagnoses including schizoaffective disorder bipolar type, morbid obesity, muscle weakness, hypertension, adult failure to thrive, muscle spasm, chronic pain, hypothyroidism, and diabetes mellitus. Review of the annual Minimum Data Set (MDS) assessment, dated 04/17/24, revealed Resident #5 was cognitively intact. On 06/14/24 at 12:16 P.M., review of a unprompted text message after a telephone interview sent from State Tested Nurse Aide (STNA) #105's cell phone to the surveyor revealed she had taken a photograph of Resident #5 wearing a pink shirt, a brief, and no pants to show the surveyor she got the resident cleaned up. On 06/14/24 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-29 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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
THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, staff interview, resident interview, review of the facility's Self-Reported Incident (SRI) 243880 and related investigation materials, the facility failed to ensure Resident #39 was treated with respect and dignity. This affected one (#39) of three residents reviewed. The facility census was 44. Findings Include: Review of the medical record for Resident #39 revealed an admission date of 01/05/23 with diagnoses including heart failure, muscle weakness, scoliosis, spondylosis with myelopathy, atrial fibrillation, hypertension, cerebral infarction, and age-related osteoporosis. Review of the care plan, revised 08/01/23, revealed Resident #39 required assistance with activities of daily living (ADLs). Interventions included cushion to wheelchair while out of bed, pendant call light which resident prefers to keep at bedside instead of wearing it, camera in room per Power of Attorney (POA) request, do not leave unattended in shower, and keep…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-29 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, staff interview, resident interview, review of the facility's Self-Reported Incident (SRI) 243880 and related investigation materials, the facility failed to protect Resident #18 from abuse by a person who was impersonating a scheduled staffing agency worker. This affected one (#18) of three residents reviewed for abuse. The facility census was 44. Findings Include: Review of the medical record for Resident #18 revealed an admission date of 09/18/23 with diagnoses including congestive heart failure, anxiety disorder, major depressive disorder, and unspecified psychosis. Review of the quarterly Minimum Data Set (MDS) Assessment, dated 12/19/23, revealed Resident #18 was cognitively intact and required substantial assistance or total dependence on staff for activities of daily living (ADLs). Review of the behavior care plan, revised on 12/22/23, revealed Resident #18's son reported Resident #18 made up stories and had beliefs in false…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-12-19 · tag F0880 — failed to prevent and control infections — patternProvide 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, interview, record review, review of facility policy, and review of Centers for Disease Control and Prevention (CDC) guidance the facility failed to maintain and implement an effective infection prevention and control program to prevent the transmission of CRE (carbapenem-resistant enterobacterales), including proper personal protective equipment (PPE) was worn by staff when entering Resident #43's room who was on enhanced barrier isolation for CRE and failed to ensure staff discarded and changed soiled gloves appropriately after providing Resident #43's incontinence care. This had the potential to affect 19 residents (#2, #4, #5, #8, #11, #13, #14, #17, #21, #23, #24, #27, #30, #31, #32, #35, #36, #40, #41) residing on the nursing unit. The facility census was 44. Findings include: Review of Resident #43's medical record revealed an admission date of 07/24/23 with diagnoses including chronic respiratory failure with hypoxia, heart failure, dementia, right and left lumbago with sciatica, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-19 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility policy the facility failed to ensure a State Tested Nursing Assistant (STNA) #374 accused of staff to resident abuse towards Resident #43 was not immediately suspended pending the outcome of an investigation. This affected one resident (#43) out of three residents reviewed for abuse. The facility census was 44. Findings include: Review of Resident #43's medical record revealed an admission date of 07/24/23 with diagnoses including chronic respiratory failure with hypoxia, heart failure, dementia, right and left lumbago with sciatica and dependence on supplemental oxygen. Review of Resident #43's progress notes dated 08/13/23 at 9:09 P.M. included this nurse, Licensed Practical Nurse (LPN) #328, went in Resident #43's room with her aide (STNA #374) to find out why Resident #43 did not want STNA #374 to care for her. Resident #43 stated she did not want STNA #374 because she was [expletive] to her when she took care of her previously. LPN #328 told…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-19 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility policy the facility failed to ensure Resident #43's allegation of staff-to-resident abuse was reported to the State Agency timely. This affected one resident (#43) out of three residents reviewed for abuse. The facility census was 44. Findings include: Review of Resident #43's medical record revealed an admission date of 07/24/23 with diagnoses including chronic respiratory failure with hypoxia, heart failure, dementia, right and left lumbago with sciatica, and dependence on supplemental oxygen. Review of Resident #43's progress notes dated 08/13/23 at 9:09 P.M. included this nurse, Licensed Practical Nurse (LPN) #328, went in Resident #43's room with her aide, STNA #374, to find out why Resident #43 did not want STNA #374 to care for her. Resident #43 stated she did not want STNA #374 because she was [expletive] to her when she took care of her previously. LPN #328 told Resident #43 she was the nurse in the room when STNA #374 expressed that she…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-19 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility policy the facility failed to ensure Resident #43's weights were checked daily according to the physician's orders. This affected one resident (#43) out of three residents reviewed for weights. The facility census was 44. Findings include: Review of Resident #43's medical record revealed an admission date of 07/24/23 with diagnoses including chronic respiratory failure with hypoxia, heart failure, dementia, right and left lumbago with sciatica, and dependence on supplemental oxygen. Review of Resident #43's physician's orders dated 07/25/23 revealed daily weight, one time a day for CHF (congestive heart failure). Review of Resident #43's weights dated 10/01/23 through 12/19/23 revealed there were eight daily weights (10/01/23, 10/21/23, 11/20/23, 11/23/23, 11/24/23, 11/30/23, 12/03/23 and 12/09/23) which were not documented as obtained according to the physician's orders. Review of Resident #43's Quarterly Minimum Data Set (MDS) 3.0 assessment dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 16 citations
- Potential for harm · Dcited before2023-12-19 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide 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 interview, record review, and review of the facility policy the facility failed to ensure Resident #43's physical therapy discharge recommendations were implemented. This affected one resident (#43) out of three residents reviewed for therapy recommendations. The facility census was 44. Findings include: Review of Resident #43's medical record revealed an admission date of 07/24/23 with diagnoses including chronic respiratory failure with hypoxia, heart failure, dementia, right and left lumbago with sciatica, and dependence on supplemental oxygen. Review of Resident #43's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #43 was cognitively intact. Resident #43 had upper extremity impairment and lower extremity impairment on both sides. Resident #43 was always incontinent of urine and bowel. Resident #43 used oxygen. Review of Resident #43's progress notes dated 10/25/23 at 11:14 A.M. included the goal was not met for Resident #43's restorative programs due to Resident #43…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-19 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility policy the facility failed to ensure Resident #43's incontinence care was completed timely. This affected one resident (#43) out of three residents reviewed for incontinence. The facility census was 44. Findings include: Review of Resident #43's medical record revealed an admission date of 07/24/23 with diagnoses including chronic respiratory failure with hypoxia, heart failure, dementia, right and left lumbago with sciatica, and dependence on supplemental oxygen. Review of Resident #43's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #43 was cognitively intact. Resident #43 had upper extremity impairment and lower extremity impairment on both sides. Resident #43 was always incontinent of urine and bowel. Resident #43 used oxygen. Review of Resident #43's care plan revised 10/31/23 included Resident #43 required assistance with majority of ADL (activity of daily living) due to respiratory failure, CHF…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-08-11 · tag F0804 — failed to serve food at safe, palatable temperature — widespreadEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure meals were served at a palatable temperature at point of service. This had the potential to affect all 39 residents who received meals from the kitchen. The facility identified eight residents (#1, #3, #4, #10, #16, #21, #22 and #23) as not receiving meals from the kitchen. The facility census was 47. Findings include: Observation of tray line on 08/11/23 at 12:11 P.M. revealed Dietary [NAME] #147 was asked by the state surveyor for a test tray at the end of the 100-unit tray cart. At 12:11 P.M. Dietary [NAME] #147 plated a test tray. The test plate was enclosed by an insulated plate cover and base and placed in a covered uninsulated meal cart. Dietary [NAME] #147 proceeded to cook special order items for the remaining four meal trays for the cart where the test tray was sitting. At 12:22 P.M., the meal cart was delivered to the 100-unit by dietary staff, and state tested nursing staff began serving the meal trays to residents residing on the 100 unit at 12:27 P.M. At 12:45 P.M., all the residents had received their…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-08-11 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and facility policy review, the facility failed to ensure all foods in cooler and freezer units were properly labeled and dated. This had the potential to affect 39 residents who received food from the kitchen. The facility identified eight residents (#1, #3, #4, #10, #16, #21, #22 and #23) as receiving nothing by mouth. The facility census was 47. Findings include: Observation of the kitchen on 08/11/23 from 10:00 A.M. to 10:25 A.M. with Registered Dietitian (RD) # 141, Manager in Training #142, and Corporate Dietitian #164 revealed the following concerns: Observation of the three-door reach in freezer located in the dry storage area revealed one opened, resealed half-full bag of peas and carrots that had no date on it. Observation of the two-door reach in freezer in the dry storage area revealed one opened, resealed half-full bag of tater tots without a date on it, and one opened one-fourth full bag of French fries without a date on it. Observation of the tray line reach in cooler revealed one opened, resealed bag of parmesan cheese and one opened,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-06-28 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and review of facility policy the facility failed to ensure appropriate hand hygiene was implemented during the medication pass for three residents (Residents #13, #14, #47), during meal time for six residents (Residents #13, #24, #26, #36, #42, #44) and failed to ensure the glucometer for Resident #33 was disinfected after it was used to check a blood sugar. This affected nine out of nine residents reviewed for infection control and had the potential to affect all 28 residents residing on the 300 nursing unit. The facility census was 49. Findings include: Observation on 06/21/22 at 12:06 P.M. revealed State Tested Nursing Assistant (STNA) #344 was passing out meal trays and assisting residents with their meals in the dining area. STNA #344 gave Resident #24 her meal tray and assisted her with the tray set up prior to her eating. After STNA #344 assisted Resident #24 he walked to the meal cart and picked up Resident #42's meal tray. STNA #344 walked over to Resident #42, set her tray on the table and assisted her with her tray set up prior to her…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-06-28 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of the facility policy the facility failed to ensure a communication book was used for one resident (Resident #48) to communicate in a language the resident understood. This affected one resident (Resident #48) out of three residents reviewed for communication. The facility census was 49. Findings include: Review of Resident #48's medical record revealed an admission date of 08/19/16 and diagnoses included malignant neoplasm of the pelvis, dysphasia following cerebral infarction, acute heart failure, anxiety and major depressive disorder. Review of Resident #48's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #48 had moderate cognitive impairment and required extensive assistance of one staff member for bed mobility and toilet use. Resident #48 required extensive assistance of two staff members for transfers, required supervision for eating and was frequently incontinent of urine and bowel. Review of Resident #48's care…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-06-28 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of the facility policy the facility failed to ensure one resident's (Resident #22) physician order for a hematology physician appointment was completed. This affected one resident (Resident #22) out of three residents reviewed for physician orders. The census was 49. Findings include: Review of Resident #22's medical record revealed an admission date of 03/19/20 and diagnoses included immune thrombocytopenic purpura (low levels of the blood cells that prevent bleeding, platelets), abnormal findings of blood chemistry, and acute kidney failure. Resident #22 was discharged from the facility on 06/21/22. Review of Resident #22's care plan dated 05/11/20 revealed Resident #22 had potential risk for abnormal bleeding secondary to anticoagulant therapy, and immune thrombocytopenic purpura. The goal indicated Resident #22 would not present with signs and symptoms of abnormal bleeding through next review date. Interventions included handle carefully when…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-06-28 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide 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 interview and record review the facility failed to initiate restorative nursing programs per therapy recommendations affecting two residents (Resident #28 and #31) out of two residents (Residents #28 and #31) reviewed for decline in activities of daily living. This had the potential to affect 17 residents (Residents #2, #4, #6, #7, #10, #14, #15, #16, #19, #20, #23, #25, #26, #28, #31, #33, #47) that were recommended to be on a restorative nursing program. Findings include: 1. Review of the medical record for Resident #28 revealed an admission date of 11/25/19 and diagnoses included chronic respiratory failure with hypoxia, morbid obesity, dependence on a ventilator, hypertension, and anxiety. Review of care plan dated 02/15/21 revealed Resident #28 required assistance with most of her activities of daily living. Interventions included assist with one to two people with bed mobility and dressing, transfer bed to chair with a mechanical lift with a two person staff assist, restorative nursing screening…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-06-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review the facility failed to ensure medications were maintained in a safe and secure manner. This affected two residents (Residents #12 and #43) out of four residents (Residents #3, #12, #18, and #43) reviewed for unsecured medications and had the potential to affect all 49 residents residing at the facility. Findings include: 1. Review of the medical record for Resident #12 revealed an admission date of 06/24/20 and diagnoses included chronic obstructive pulmonary disease (COPD) with acute exacerbation, chronic respiratory failure with hypoxia, solitary pulmonary nodule, adult failure to thrive, dependence of oxygen, and Alzheimer's disease. There was no medication self-administration assessment in her medical record. Review of care plan dated 07/13/20 revealed Resident #12 had Alzheimer's disease and a decline in cognition, mobility and activities of daily living was expected due to disease process. Interventions included explain all procedures prior 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.
- Potential for harm · D2022-06-28 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure medical records were complete and accurate for Residents #31 and #43. This affected two residents of six residents (Residents #5, #12, #28, #31, #43 and #250) reviewed for nutrition and Activities of Daily Living (ADL). Findings include: 1. Review of the medical record revealed Resident #31 was admitted on [DATE] with diagnoses including acute kidney failure, major depressive disorder, unspecified dementia without behavior, protein calorie malnutrition and Alzheimer's disease. Review of the quarterly Minimum Data (MDS) 3.0 assessment of 05/03/22 revealed the resident was severely cognitively impaired and required total dependence of two for ADLs. Review of the care plan of 05/26/22 revealed a care area for hospice services (added 08/09/21) for a terminal diagnosis of Alzheimer's disease. Review of the electronic and paper charts for Resident #31 revealed no documentation from hospice beyond their contact information. Interview on 06/23/22 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2019-06-27 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure safe and sanitary food storage, meal service and equipment. These deficient practices affected 45 residents receiving food from the kitchen (Resident #10, Resident #15 and Resident #18 were identified by the facility as receiving nothing by mouth and did not receive meals from the kitchen). The facility census was 48 residents. Findings include: 1. Tour on 06/24/19 from 9:24 A.M. to 9:50 A.M. with Food Service Director (FSD) #500 revealed a refrigerator used for resident food storage. A sign on the refrigerator directed visitors and staff to please label and date all items and stated that anything inside six days past the original date on the food item would be discarded. The facility policy regarding food brought in from outside visitors was also posted on the refrigerator. A piece of cake, bowl of spaghetti, block of cream cheese, a cup of yogurt dated 06/11/19 and three containers were noted to be unlabeled and undated in 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.
- Potential for harm · Dcited before2019-06-27 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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 observation, interview and record review the facility failed to ensure residents were treated with respect and dignity during care. This affected one resident (Resident #6) of four residents reviewed for dignity. The facility census was 48 residents. Findings include: Review of Resident #6's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including polymyalgia rheumatica, polyosteoarthritis, diverticulosis of intestine, without perforation or abscess, depressive disorder, anxiety disorder and transient cerebral ischemic attack. Review of Resident #6's quarterly Minimum data set 3.0 assessment dated [DATE] revealed the resident required and extensive assist of two persons for bed mobility and transfers and one person assist for dressing, toilet use and personal hygiene. Resident #6 Brief Individual Mental Status score was 15 which identified the resident as cognitively intact. Further review of Resident #6 plan of care revealed the resident did not have a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-06-27 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide Resident #195 a copy of her baseline plan of care. This affected one of three new admission residents reviewed. The facility census was 48. Findings include: Review of Resident #195 medical record revealed the resident was admitted on [DATE] with diagnoses of sock sinus syndrome, anxiety disorder atrial fibrillation, and cardiac pacemaker Review of Resident #195 Minimum Data Set, dated 06/21 /19 revealed and admission assessment had been started and was in the process of completion. Resident #195's Baseline Plan of Care was located at the nurse's station. The Baseline Plan of Care had an area for resident and family signatures on receipt of the baseline plan of care. Resident #195's Baseline Plan of Care did not have the residents signature or a family member's signature as receiving the baseline plan of care. Interview with Resident #195 on 06/25/19 at 1:30 P.M. revealed she did not receive a copy of her baseline plan of care. Resident #195…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-06-27 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility did not ensure Resident #35's comprehensive assessment was implemented to ensure the resident used her call light prior to unassisted ambulation. This affected one of 12 residents reviewed for implementation of comprehensive care plans. The facility census was 48. Findings include: Review of Resident #35's medical record revealed the resident was admitted to the facility 10/11/18 with diagnoses of chronic obstructive pulmonary disease, fracture of unspecified part of right clavicle, initial encounter for closed fracture, dissection of thoracic aorta, anxiety disorder, and insomnia. Review of Resident #35's quarterly Minimum Data set 3.0 dated 05/28/19 revealed the resident required an extensive assist of two persons for bed mobility and extensive assist of one person for transfers, dressing, toilet use and personal hygiene. Review of Resident #35's plan of care dated 05/10/19 revealed the resident was at risk for falls characterized by impaired balance, impaired mobility, pain, psychoactive drug use, noncompliance with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-06-27 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure Resident #197 catheter tubing was not in contact with floor. This affected one of three residents reviewed for catheter care. The facility census was 48. Findings include: Review of Resident #197's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia without behavioral disturbance, dyspnea, cerebral infarction and cardiac arrest. Resident #197 Minimum Data Set had not been completed. Review of Resident #197's Baseline Plan of Care dated 06/23/19 documented the resident had the use of a catheter for incontinence. Observation of Resident #197 on 06/24/19 at 11:20 A.M., 06/24/19 at 1:50 P.M. revealed the resident's catheter tubing was dragging on the floor in direct contact with floor. The observation was verified with Licensed Practical Nurse (LPN) #508 on 06/24/19 at 1:50 P.M. On 06/26/19 at 7:13 A.M. Resident #197 in bed. on her right with the catheter [NAME] on the left side…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2019-06-27 · tag F0577 — widespreadAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and staff interview the facility failed to have three years of state survey results, including complaint investigations, readily accessible to residents and the general public. This had the potential to affect all 48 residents residing in the building. Findings include: Review of the facility survey book on 06/25/19 at 6:15 P.M. revealed the last recorded survey results were from the annual survey dated 08/09/18. The Ohio Department of Health conducted complaint investigations at the facility on 01/11/19, 03/13/19, 03/26/19, 04/05/19 and 05/20/19. The results of these surveys were not in the survey book at the time of observation. Interview with the Administrator on 06/25/19 at 6:17 P.M. verified that the listed surveys were not present in the book at the time of observation.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| BERARDINO, NICHOLAS | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 25% | since 09/28/2018 |
| CILONE, JOSEPH | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 25% | since 09/28/2018 |
| HUBER, MICHAEL | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 25% | since 09/28/2018 |
| LUMENT REAL ESTATE CAPITAL LLC | Organization | 5% OR GREATER MORTGAGE INTEREST | — | since 03/18/2022 |
| JCTH HOLDINGS, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 09/28/2018 |
| FOY, VALERIE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/23/2023 |
| MULLEN, LESLIE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/15/2024 |
| RASTOGI, VIJAY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/01/1970 |
| VAIL DRIVE PROPERTY HOLDINGS, LLC | Organization | ADP OF THE SNF | — | since 04/09/2025 |
| PETROZZI, LARRY | Individual | ADP OF THE SNF | — | since 09/28/2018 |
CMS files one row per role, so the 20 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.
3 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.
About 85% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.0M paid to related parties — landlords or management companies under common ownership — equal to about 13% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Ohio Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 366385. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-11-14, 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.