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Manor Of Grande Village

2610 East Aurora Road, Twinsburg, OH 44087 · For profit - Corporation · 88 certified beds · (330) 963-3600 Medicare & Medicaid certified

Call the home — (330) 963-3600 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Jun 2024Behavioral-health or dementia-care citation — no harm found (F0744)
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2024
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • about 17% of its spending goes to commonly-owned related companies
  • 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.

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

Location & what’s nearby

Urgent care / clinic
8819 Commons Blvd Ste 202 · (216) 844-7191 · Call to confirm hours
Pharmacy
Designrx0.4 mi
2181 E Aurora Rd · (877) 416-6600 · Call to confirm hours
Grocery
8960 Darrow Rd · (330) 405-1900 · Call to confirm hours
Park
(330) 425-4497 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 1 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 increased2.0%5.3%15.4%better than state — see note marked double-dagger below the table
Long-stay residents who lose too much weight5.7%6.2%5.4%typical
Long-stay residents with a catheter left in their bladder0.0%0.2%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.4%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms10.3%30.1%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury1.2%3.2%3.3%better
Long-stay residents whose ability to walk worsened2.4%6.1%16.1%better than state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication36.0%25.5%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%94.5%95.3%typical
Long-stay residents with pressure ulcers2.3%3.4%4.7%better
Long-stay residents with worsening bladder/bowel control27.8%21.4%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table9.1%8.8%17.1%better
Short-stay residents who newly got an antipsychotic medication1.8%1.2%1.4%worse
Short-stay residents given the seasonal flu vaccine92.7%75.6%79.4%better
Short-stay residents rehospitalized after admission20.2%24.9%22.6%better
Short-stay residents with an outpatient ER visit15.3%12.9%12.0%worse

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

43.1% 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 51 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

43.1%U.S. median 51.5%
Got home and stayed home
10.0%U.S. median 10.7%
Went back to hospital
30.0%U.S. median 56.6%
Met the expected recovery
0.39U.S. median 0.31
Therapy hours / resident / day
0.22hours / resident / day
Physical therapy
0.14hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 30.0% 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 40 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 0.39 therapist hours per resident per day in 2026Q1 — more than 68% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 19% 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 SNF43.1%CMS range 33.0–56.651.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.0%CMS range 6.1–14.210.7%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 discharge30.0%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 discharge37.5%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 discharge32.5%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 identified96.0%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 settingnot 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 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 stay2.0%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 worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.1%CMS range 3.1–13.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.061.02Oct 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

0.58
RN hours/ resident / day
0.92
LPN hours/ resident / day
1.94
Aide hours/ resident / day
3.43
Total nurse hours/ resident / day
0.40
RN hoursweekends
43.2%
Total nursing turnover
33.3%
RN turnover

How full it usually is: this home is certified for 88 beds and averages 79.7 residents a day — about 91% occupied, or roughly 8 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 3.43 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.58 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.94 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 3.13 hrs/resident/day on weekends vs 3.56 on weekdays — 12% thinner on weekends. RN hours go from 0.66 to 0.40 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 43% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

5
deficiencies at the latest standard inspection (2024-07-02)
16
at the previous standard inspection (2022-04-22)

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.

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.

27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.

  • Potential for harm · Fcited before2024-07-02 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interview, and facility policy review the facility failed to ensure the kitchen was clean and sanitary. This had the potential to affect all 73 residents that received meals from the facility. No residents were identified as receiving nothing by mouth. The facility census was 73. Findings include: Observation during a tour of the kitchen on 06/30/24 from 8:10 A.M. to 8:30 A.M. with [NAME] #566 revealed Dietary Aide (DA) #601 had a full beard with no beard net on while in the kitchen. DA #601 stated on 06/30/24 at 8:10 A.M. that he should have been wearing a beard net. Observation of the walk-in refrigerator revealed salad mix not labeled or dated, meatballs in a pan with a ripped foil cover, and a half of an undated cucumber. The door to the dining room and plate warmer had food splatter and food residue on it. The identified findings were verified at the time of observations with [NAME] #566. A revisit to the kitchen for tray line observation on 07/01/24 revealed that one food cart was dirty with food splatter on the door and inside. This was verified by…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-07-02 · tag F0805 — failed to prepare food in a form residents can eat — pattern
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, interview, taste test and pureed/mechanical soft guidelines review, the facility failed to serve pureed foods at a smooth consistency for safe swallowing. This had the potential to affect four residents (#1, #22, #46, and #58) who were prescribed pureed diets of 73 residents who consumed meals from the facility's kitchen. The facility census was 73. Findings include: Observation and interview on 07/01/24 at 10:45 A.M. revealed [NAME] #566 pureed hamburgers, and they were the proper consistency. [NAME] #566 then pureed the French fries and portioned a sample into a monkey dish for the taste test. The French fries were contained lumps and were not a smooth consistency. Regional Dietary Manager #600 verified on 07/01/24 at 11:00 A.M. and stated [NAME] #566 should puree the French fries more. The French fries were pureed correctly prior to service. The facility identified four residents (#1, #22, #46, and #58) who were prescribed pureed diets. Review of the facility's pureed/mechanical soft guidelines revealed pureed foods should be pureed until smooth.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-02 · 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 record review, observation, and interview the facility failed to ensure call lights were within reach of Residents #37 and #176. This affected two residents (#37 and #176) of 73 residents residing at the facility. Findings include: 1. Review of the medical record for Resident #37 revealed an admission date of 02/20/21 with diagnoses including multiple sclerosis, heart failure, dementia, depressive disorder, acute kidney failure, Parkinson's, and difficulty walking. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #37 had intact cognition and required moderate assistance of staff for eating, bed mobility, transfers, and hygiene. Review of the care plan dated 04/26/24 revealed Resident #37 had a history of falls related to Parkinson's, weakness, and dementia. Intervention included keeping the call light within reach. Observation on 06/30/24 at 9:45 A.M. of Resident #37 revealed she was lying in bed, and her call light was lying on the floor next to her bed.…

    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 before2024-07-02 · 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 and interview, the facility failed to ensure Resident #29's code status was accurately reflected in both the hard medical chart and the electronic medical record. This affected one resident (#29) of 73 residents reviewed for advanced directives. The facility census was 73. Findings include: A review of Resident #29's hard medical chart revealed he was admitted to the facility on [DATE] with diagnoses of heart failure, end stage renal disease, and hypothyroidism. A document with the words, Full Code, was located on the face sheet in the electronic chart. A full code status means all emergency life saving measures will be provided in the event of respiratory arrest or cardiac arrest. Review of Resident #29's medical record dated 01/03/24 located in the hard chart revealed a code status of Do Not Resuscitate-Comfort Care Arrest (DNR-CCA). A DNR-CCA means a person would receive all emergency and medical care up until the time he or she experiences a cardiac or respiratory arrest, then all…

    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 before2024-07-02 · 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 — the official record, unedited, may be distressing

    Based on observation and interview, the facility failed to ensure Insulin KwikPens and insulin vials were dated when opened. This affected three residents (#3, #7, and #226) of twelve residents who were identified by the facility as receiving insulin. The facility census was 73. Findings include: Observation on 06/30/24 at 11:19 A.M. of a medication cart revealed two KwikPens not dated when opened, for Residents #3 and #7, and one used insulin vial not dated when opened for Resident #226. Interview at the time of the observation, Registered Nurse (RN) #530 stated all insulin pens should be dated when initially opened during the observation. Review of the facilities policies and procedures revealed no policy for insulin storage. This was verified by the Director of Nursing on 07/01/24 at 3:35 P.M.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-04 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, review of three self-reported incidents (SRIs) and interviews the facility failed to ensure Resident #52 was free from physical abuse by Resident #54. This affected one resident (Resident #52) of five residents reviewed for abuse. The census was 76. Findings include: Review of SRI #244843 started on 03/05/24 and timed at 6:36 P.M. and completed on 03/11/24 and timed at 3:33 P.M. revealed Resident #54 struck Resident #52 several times on the left eye and left side of face. Staff separated immediately, assessed, completed skin checks and vitals. Immediate interventions put in place were one-on-one supervision, then every 15-minute checks for two days, deep-breathing and distraction. Review of progress noted dated 03/05/24 revealed Resident #54 had a new order for Ativan as needed for 14 days. Physician assistant and psychiatry consultations were ordered. Review of progress note on 03/08/24 revealed a care conference was held with the responsible party where the abuse policy was reviewed…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-13 · 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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, review of safety data sheets, review of job descriptions, and review of facility policy, the facility failed to ensure corrosive toilet cleaning products were securely stored on the memory care unit. This affected one resident (Resident #50) of three residents reviewed for accident hazards and had the potential to affect the 11 other residents (#1, #18, #19, #38, #40, #44, #46, #47, #54, #68, and #70) the facility identified as being independently ambulatory, cognitively impaired, and resided on the memory care unit. The facility census was 73. Findings include: Review of the medical record for Resident #50 revealed an admission date of 01/14/23. Diagnoses included cerebral infarction (stroke), dementia, Alzheimer's disease, and unspecified disorientation. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] 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.

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · F2022-04-22 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and staff interview the facility failed to maintain the services of a registered nurse for at least eight consecutive hours a day, seven days a week. This had the potential to affect all 76 residents currently residing in the facility. Findings include: Review of the staffing schedules from 04/14/22 through 04/17/22 revealed no registered nurses (RNs) were working in the facility on 04/17/22. Review of the posted nursing staff information for 04/17/22 revealed no RNs were present in the facility on this date. Interview on 04/21/22 at 6:46 P.M. with Human Resources #511 verified there were no RNs working in the facility on 04/17/22.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2022-04-22 · tag F0761 — failed to label and store drugs safely — widespread
    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, interview and review of facility policy the facility failed to date and store opened medications properly and failed to dispose of expired medications. This had the potential to affect all 76 residents residing in the facility. Findings include: Observation on 04/20/22 at 9:32 A.M. on the secured nursing unit revealed one five milliliter (ml) bottle of Sanofi brand influenza vaccine opened and undated in the refrigerator and one tuberculin (TB) purified protein derivative 0.1 ml bottle opened and undated. Interview with Licensed Practical Nurse (LPN) #659 at the time of the observation verified the influenza and TB vaccine bottles did not have an opened date. LPN #659 indicated the refrigerator was shared between the secured nursing unit and another nursing unit. Observation on 04/20/22 at 9:55 A.M. of the medication cart for the secured nursing unit revealed two one calcitonin nasal spray opened and undated, one fluticasone propionate for Resident #7 opened and undated, albuterol sulfate inhalation aerosol for Resident #3 opened and undated and a bottle of…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2022-04-22 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, review of facility policy, and review of the Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure appropriate use of personal protective equipment (PPE) for one resident (Resident #278) on Transmission Based Precautions (TBP), failed to enusre reusable non-critical care equipment was disinfected after each resident use, and failed to ensure linens for residents on TBP were processed appropriately in the laundry area. This had the potential to affect all residents residing in the facility. The facility census was 76. Findings include: 1. Review of Resident #278's medical record revealed an admission date of 04/12/22 and diagnoses including diabetes mellitus, Bell's Palsy and hyperlipidemia. Resident #278 was on transmission based precautions due to being an unvaccinated new admission. Observation on 04/20/22 at 7:34 A.M. revealed a plastic cart with personal protective equipment (PPE) outside of Resident #278's room, a door covering with PPE, and a sign on the door for Transmission Based Precautions…

    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
Show the remaining 17 citations
  • Potential for harm · E2022-04-22 · tag F0623 — pattern
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility failed to ensure a resident received notice of discharge in a timely manner. This affected one resident ( Resident #20) of one resident reviewed for discharge from facility. The facility also failed to ensure written notice of hospital transfers including the reason for the transfer were given to the resident or their representative and were provided to the long term care (LTC) Ombudsman in a timely manner. This affected three residents (#30, #33, and #50) of three residents reviewed for hospitalization. The facility census was 76. Findings include: 1. Review of the medical record for Resident #20 revealed an admission date of 12/23/21. Diagnoses included dysphasia, schizophrenia, anxiety, and depression. Review of the accounting notes dated 03/17/22 revealed Resident #20 was provided with a 30-day discharge letter on 03/17/22. Review of the undated 30-day discharge notice, revealed Resident #20 would be discharged on 04/16/22 due to the resident being cut…

    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 before2022-04-22 · 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 interview, record review and review of the facility policy, the facility failed to ensure advance directives (level of medical interventions a resident wishes to have performed in the event they experience an absence of a heartbeat or breathing) were located in the medical record. This affected two (Residents #32 and #66) of two residents reviewed for advanced directives. The facility census was 76. Findings include: 1. Review of the medical record for Resident #32 revealed an admission date of 02/04/22 with diagnoses that included Alzheimer's Disease, hypertension, osteoarthritis and glaucoma. Review of the physician's orders dated 12/24/21 revealed an order for do not resuscitate, comfort care only, arrest (DNRCC-A). This meant the resident was to receive standard medical care until her heart stopped beating or she stopped breathing. Review of the physical chart for Resident #32 revealed no evidence of the State of Ohio DNR form. Interview on 04/20/22 at 8:57 A.M. with Licensed Practical Nurse (LPN)…

    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 · D2022-04-22 · tag F0609 — failed to report abuse allegations — isolated
    Timely 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 and record review, the facility failed to report suspicion of abuse to the State agency within the required time frame. This affected two residents (#5, and #15) of four residents reviewed regarding submitted Self-Reported Incidents (SRIs). Facility census was 76. Findings include: Review of the medical record for Resident #5 revealed an admission date of 11/16/20. Diagnosis included dementia without behavioral disturbance. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5's cognition was not assessed and the resident was independent with bed mobility, required limited assistance of one staff for transfers, and supervision of one staff for ambulation. Review of the progress note dated 03/30/22 at 5:33 P.M. revealed a state tested nurse aide (STNA) notified the nurse Resident #5 attempted an inappropriate sexual act with another resident (Resident #15). Both residents were placed on 15 minute checks for 24 hours. The Unit Manager 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-04-22 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of a facility Self-Reported Incident (SRI) and investigation, and staff interview, the facility failed to thoroughly investigate an allegation of sexual abuse for two residents (Residents #5 and #15). This affected two residents (Resident's #5 and #15) out of four residents reviewed for abuse. The facility census was 76. Findings include: Review of the SRI dated 03/31/22 for alleged sexual abuse involving Residents #5 and #15 revealed Resident #5 and Resident #15 were witnessed by a State Tested Nurse Aide (STNA) attempting to engage in a sexual act. The witness statements in the investigative file included typed phone interviews completed by the Administrator. The witness statements were from Housekeeping Aide (HA) #580, STNA #586 and Agency Nurse #588. All three statements confirmed it looked like Residents #5 and #15 were attempting to engage in a sexual act. The statements were not signed and did not contain details regarding what was actually witnessed. Agency Nurse #588's typed statement indicated both residents were placed on 15 minute checks, skin checks 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-04-22 · tag F0635 — isolated
    Provide doctor's orders for the resident's immediate care at the time the resident was 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 record review and staff interview, the facility failed to obtain an order for dialysis upon admission for one (#279) out of one resident reviewed for dialysis services. The facility identified two current residents who received dialysis services. The facility census was 76. Findings include: Review of the medical record for Resident #279 revealed the resident was admitted to the facility on [DATE]. Diagnoses included end stage renal disease, hypothyroidism, and anemia. Resident #279 was receiving dialysis services prior to admission. Further medical record review revealed documentation of Resident #279 receiving dialysis on 04/08/22, 04/11/22, 04/13/22, 04/15/22, 04/18/22, and 04/20/22. Review of Resident #279's admission physician orders and subsequent orders revealed an order for Resident #279 to receive dialysis every Monday, Wednesday, and Friday beginning on 04/13/22. There was no order for the resident to receive dialysis services prior to 04/13/22. Interview on 04/21/22 at 1:17 P.M. with 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-04-22 · 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, interview, record review, and review of facility policy the facility failed to ensure care planned interventions were implemented to prevent one resident (Resident #7) from obtaining the code and entering a secured area on the nursing unit she resided on. This affected one resident (Resident #7) out of three residents reviewed for supervision. The facility census was 76. Findings include: Review of Resident #7's medical record revealed an admission date of 12/30/20 and diagnoses including dementia, type two diabetes mellitus, and macular degeneration. Review of Resident #7's care plan dated, 02/11/21 revealed Resident #7 had the potential for injury and was an identified wanderer related to Alzheimer's disease, dementia, confusion, and desire to go home. The goal indicated Resident #7 would wander in safe locations and would have safety maintained. Interventions included to know Resident #7's whereabouts, attempt to divert, determine pattern to wandering, report episodes, exit door alarms…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-04-22 · 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 observation, interview, record review, and review of the facility policy the facility failed to implement care planned interventions to ensure one resident's (Resident #46) incontinence care was completed timely. This affected one resident (Resident #46) out of three residents reviewed for incontinence care. The facility census was 76. Findings include: Review of Resident #46's medical record revealed an admission date of 08/13/16 and diagnoses including Alzheimer's disease, anxiety, dementia and restlessness, and agitation. Review of Resident #46's Quarterly Minimum Data Set (MDS) 3.0 assessment dated , 03/09/22, revealed Resident #46 was rarely or never understood. Resident #46 required the extensive assistance of two staff members for bed mobility, transfers, toilet use, and was always incontinent of urine and bowel. Resident #46 had little interest or pleasure in doing things, was feeling down, had trouble falling or staying asleep, was short tempered and easily annoyed. Review of Resident #46's care plan dated, 03/23/22 revealed Resident #46 was incontinent with 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 · D2022-04-22 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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 implement care planned interventions to timely identify a significant weight loss for Resident #75 and notify the dietitian. This affected one resident (Resident #75) out of one resident reviewed for weight loss. The facility census was 76. Findings include: Review of the medical record for Resident #75 revealed an admission date of 01/28/22 with diagnoses of severe protein calorie malnutrition, acute cystitis with hematuria, muscle weakness, hypothyroidism, and hypertension. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated she was moderately cognitively impaired. The MDS also indicated the resident was malnourished. Review of Resident #75's admission weight on 01/28/22 revealed a weight of 120.0 pounds. Review of the care plan dated 01/31/22 revealed Resident #75 was at risk for…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-04-22 · tag F0744 — failed to care for residents with dementia — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    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 supervision was provided Residents #5 and #15, and failed to ensure staff were knoweldgable regarding how to approach Resident #46 to ensure timely provision of incontinence care. This affected three of 25 residents residing on the secured dementia unit. The facility census was 76. Findings include: 1. Review of the medical record for Resident #5 revealed an admission date of 11/16/20 with diagnoses of major depressive disorder, dementia, muscle weakness and hypoxemia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #5 was rarely or never understood when communicating and needed substantial assistance in almost all activities of daily living (ADLs). Review of the care plan dated 04/19/22 for Resident #5 revealed a problem with disruptive sexual interaction and dementia with a goal to interact with others and staff appropriately. The interventions…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-04-22 · 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 the attending physician documented in the resident's medical record that the pharmacist's drug reviews were reviewed and what, if any, action was taken to address the recommendations. This affected two residents (#25 and #33) of five residents (#25, #30, #31, #33, and #44) reviewed for unnecessary medications. The facility census was 76. Findings include: 1. Review of the medical record for Resident #25 revealed an admission date of 05/08/21. Diagnoses included Guillain-Barre syndrome, muscle weakness, and difficulty in walking, diastolic (congestive) heart failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25's cognition was not assessed and the resident required extensive assistance of two staff for bed mobility, extensive assistance of two staff for transfers, and total dependence of one staff for toilet use. Review of the pharmacy recommendation dated 12/22/21 revealed Resident #25 had an…

    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 · D2022-04-22 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident interview, and staff interview, the facility failed to ensure Resident #279 received medication per physician's order upon returning from dialysis. This affected one (Resident #279) of one resident reviewed for dialysis. The facility identified two current residents receiving dialysis. The facility census was 76. Findings include: Review of the medical record for Resident #279 revealed the resident was admitted to the facility on [DATE]. Diagnoses included end stage renal disease, hypothyroidism, and anemia. Resident #279 was receiving dialysis services prior to admission. Review of the admission assessment dated [DATE] revealed Resident #279 was cognitively intact. Review of the physician orders for Resident #279 revealed an order dated 04/07/22 for two 800 milligram (mg) tablets of Sevelamer (phosphate binder) three times per day for chronic kidney disease. Further review of the medical record revealed Resident #279 received dialysis on 04/08/22, 04/11/22, 04/13/22, 04/15/22,…

    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 · D2022-04-22 · tag F0919 — failed to provide a working call system — isolated
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and staff interviews, the facility failed to ensure call lights were in good repair and accessible to the resident. This affected one resident (#49) of one resident reviewed for physical environment. Facility census was 76. Findings include: Observation on 04/19/22 at 8:58 A.M. revealed Resident #49's call light was on the floor and not accessible to the resident. Observation on 04/20/22 at 9:16 A.M. revealed Resident #49's call light cover was hanging off the wall and the call light cord was not accessible to the resident. Interview 04/20/22 at 9:19 A.M. with State Tested Nurse Aide (STNA) #584 verified the above observation. STNA #584 said she worked on Monday night, and the it was like that then. Observation on 04/20/22 at 9:23 A.M. with Maintenance Director (MD) #557 verified the call light cover was hanging off the wall and the call light cord was not accessible to the resident. MD #557 stated he was not made aware Resident #49's call light was not in working order. MD #557 immediately fixed Resident #49's call light and handed him the call light after…

    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 · Fcited before2019-03-07 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to appropriately store, label and date bread items and frozen items in the reach in freezer. This had the potential to affect 63 residents in the facility who receive food from the kitchen. The facility identified one resident, Resident #267, who was ordered nothing by mouth. The facility census was 64. Findings include: During the initial kitchen tour on 03/04/19 at 9:00 A.M. with Dietary Manager (DM) #500, a bread cart was observed with six and a half loaves of white bread, fourteen loaves of wheat bread, thirteen packages of white dinner rolls, and four packages of white sandwich buns which were all undated and did not have a good if used by date. DM #500 and Dietary Technician (DT) #501 verified on 03/04/19 at 9:00 A.M. these bread items did not have dates. DM #500 stated the facility received the bread frozen from the supplier twice a week and the facility would then remove the bread from the freezer as needed. DM #500 verified the bread should have been dated when removed from the box from the freezer. Observation 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2019-03-07 · tag F0814 — failed to dispose of garbage properly — widespread
    Dispose of garbage and refuse properly.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interviews, the facility failed to keep the trash dumpster area free from debris. This had the potential to affect all of the 64 residents residing in the facility. Findings include: During the initial kitchen tour on 03/04/19 at 9:00 A.M. with Dietary Manager (DM) #500, the facility trash dumpster, located outside, was observed. There were 10 large trash bags filled with trash laying on the ground around the bottom of the dumpster. DM #500 verified this observation and concern at 9:14 A.M.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-03-07 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    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 Minimum Data Set (MDS) assessments were completed accurately for Residents #19, Resident #33, and Resident #41. This affected three of 17 residents reviewed for accurate MDS assessments. Findings include: 1. Resident #19 was initially admitted to the facility on [DATE] with diagnoses including obsessive compulsive disorder, anxiety disorder, major depressive disorder, and mood disorder. Review of the Medication Administration Record (MAR) for March 2018 Resident #19 received the following MDS monitored medications: Abilify (an antipsychotic) 10 milligrams (mg) every morning, Basaglar (an insulin) injection of 10 units at bedtime, and Clomipramine (an antidepressant) 100 mg at bedtime. Resident #19's quarterly MDS assessment with an assessment reference date (ARD) of 03/24/18 stated Resident #19 did not receive any insulin injections, any antipsychotic medication, or any antidepressant medications during the assessment reference period. Review of…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-03-07 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to administer medications with an error rate of 5% or less. This affected Resident #20 and Resident #28, two of six residents observed receiving medications. There were two errors out of 26 opportunities resulting in an error rate of 7.69%. Findings include: 1. Observation on 03/07/19 at 8:02 A.M. revealed Licensed Practical Nurse (LPN) #502 was administering medications to Resident #20. LPN #502 administered cholecalciferol tablet, a vitamin D supplement, 1,000 units orally. Record review for Resident #20 revealed a physician order written on 12/14/18 for a cholecalciferol tablet, 10,000 units daily. Review of the physician order summary report dated 03/01/19 revealed there continued to be an active physician order for cholecalciferol tablet, 10,000 units daily. Interview with LPN #502 on 03/07/19 at approximately 8:50 A.M. verified the incorrect dose of cholecalciferol had been administered to Resident #20. 2. Observation on 03/07/19 at 8:27 A.M. revealed LPN #503 administered two chewable calcium carbonate…

    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
  • No harm found · C2022-04-22 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and staff interview the facility failed to ensure daily posted nursing staff information was posted and timely updated. This had the potential to affect all 76 residents residing in the facility. Findings include: Observation on 04/18/22 at 8:33 P.M. revealed the daily posted nursing staff information was not posted. Interview at this time with the Administrator revealed the information was usually at the receptionist desk. The Administrator pointed to an empty plastic holder posted on wall behind the receptionist desk. Interview on 04/18/22 at 8:36 P.M. with the Administrator verified the daily posted nursing staff information was not posted. Observation on 04/19/22 at 9:49 A.M. revealed the daily posted nursing staff information was dated 04/18/22. Interview at this time with the Administrator and Receptionist #533 verified the daily posted nursing staff information was dated 04/18/22 and the information for 04/19/22 was not yet posted.

    Nursing and Physician Services 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 SPRENGER HEALTH CARE SYSTEMS — 12 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 53.3-0.3 vs chain
Health inspection 3 of 53.1-0.1 vs chain
Staffing 3 of 52.8+0.2 vs chain
Quality measures 4 of 54.5-0.5 vs chain
The other 11 homes this chain runs (chain average 3.3★, 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
BLUESKY HEALTHCARE INCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 02/21/2007
HUTSENPILLER, WENDIEIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF18%since 01/01/2008
MALANOWSKI, KENNETHIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF20%since 02/16/2007
SPRENGER, NICOLEIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF31%since 07/01/2008
SPRENGER, TRACEYIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF31%since 02/16/2007
FOX, EMILYIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/31/2024
KUHN, SHANNONIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/31/2024
MALANOWKI, BRANDONIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/31/2024
CMS & CO. MANAGEMENT SERVICES, INC.OrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/02/2007
AGARWAL, RAJESHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/15/2007
COURTOCK, MELISSAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/02/2002
EPPERLY, ROBERTIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/20/2022
GOLLINGER, KRISTENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/13/2000
KILBANE, KEVINIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/01/2021
MARINO-FREETAGE, JAIMEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2011
MICALE, JACOBIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/20/2023
TIEFENBACH, KATHERINEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/13/2022
BSH INVESTMENTS LLCOrganizationADP OF THE SNFsince 01/05/2006
CITRIN COOPERMAN AND COMPANY, LLPOrganizationADP OF THE SNFsince 02/01/2025
DELTA HEALTH CARE CONSULTANTS, INC.OrganizationADP OF THE SNFsince 01/01/2008
GV RENTAL PROPERTIES, LLCOrganizationADP OF THE SNFsince 01/05/2006
HUNTINGTONOrganizationADP OF THE SNFsince 07/02/2007
WELLSPRING STAFFING, INC.OrganizationADP OF THE SNFsince 10/15/2021
SAWULSKI, JENNIFERIndividualADP OF THE SNFsince 07/01/2008
SKIDMORE, JODIIndividualADP OF THE SNFsince 07/01/2008

CMS files one row per role, so the 44 rows in the source record cover these 25 parties — each is shown once here with every role it holds. Nothing is omitted.

8 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.

$8.3M
Net patient revenuemost recent cost report
-6.9%
Operating marginrevenue minus expenses
$1.5M
Related-party expense17% of expenses
Who pays — share of resident-days
Medicaid 19%Medicare 4%Other / private 77%

This home reported $1.5M paid to related parties — landlords or management companies under common ownership — equal to about 17% 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

$324per resident / day
operating cost
$9,860per month
≈ monthly operating cost
$303per 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 366346. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-07-02, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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