Sanctuary Wadsworth
365 Johnson Rd, Wadsworth, OH 44281 · For profit - Limited Liability company · 79 certified beds · (330) 335-1558 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- 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
- it has 1 actual-harm citation
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 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
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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 | 2 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 4 to 5 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 | 2.4% | 5.3% | 15.4% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 4.0% | 6.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.5% | 0.2% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.4% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 10.3% | 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 | 0.5% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 11.7% | 6.1% | 16.1% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 25.1% | 25.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.9% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 13.7% | 21.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 15.1% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.7% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 93.4% | 75.6% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 22.5% | 24.9% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 12.4% | 12.9% | 12.0% | typical |
‡ 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.
47.6% 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 29 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 44.4% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 27 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 0.17 therapist hours per resident per day in 2025Q4 — more than 17% of the 13,714 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 24% 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 14% — 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 | 47.6%CMS range 34.0–67.5 | 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 | 10.5%CMS range 6.5–16.0 | 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 | 44.4% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 40.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 40.7% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 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 | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this 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 | 0.99 | 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 79 beds and averages 67.3 residents a day — about 85% occupied, or roughly 12 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.79 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.66 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.16 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.44 hrs/resident/day on weekends vs 4.15 on weekdays — 17% thinner on weekends. RN hours go from 1.00 to 0.49 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 42% 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
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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.
23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.
- Actual harm · G2026-07-20 · 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 record review, observation, interviews, and facility policy review, the facility failed to assess and treat Resident #10's pain prior to or during wound care to her sacrum. Actual Harm occurred on 07/09/26 when Resident #10 was observed to verbalize pain every four seconds during a 23-minute continuous observation of care and her pain was not assessed or treated until care was complete, at which time her pain was rated as a 10 out of 10 (on a scale of 1 to 10 with 10 being the greatest amount of pain one could experience). This affected one (Resident #10) of two residents observed for wound care. The facility census was 64.Findings include:Review of the medical record for Resident #10 revealed an admission date of 06/09/23 with diagnoses including peripheral vascular disease, diabetes mellitus, anxiety, chronic kidney disease, cognitive communication deficit, heart failure and polyosteoarthritis.Review of the care plan dated 06/12/23 for Resident #10 revealed she had altered comfort as evidence 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.
- Potential for harm · F2026-07-20 · 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 policy review the facility failed to ensure a sanitary kitchen and resident refrigerators were maintained to prevent food spoilage. This had the potential to affect all 59 residents receiving meals from the kitchen, as five residents (Residents #4, #27, #31, #63, and #64) received nothing by mouth. The facility census was 64.Findings include: 1. Observation on 07/08/26 at 11:08 A.M. during lunch meal service revealed Dietary #514 had a hair net on but hair on the back of her neck was not restrained and the line of the hair net was approximately an inch above the exposed hair. At the time of the observation Dietary Manager #510 confirmed the observation. Observation on 07/08/26 at 12:31 P.M. revealed Dietary Manager #510's hairnet was raised off of her hairline and not all hair was contained around her ears and at the base of her neck. Dietary #518's hairnet was pushed back from the top of her hairline several inches and was not fully contained. Dietary #526's hairnet was not fully covering the hair above her ears and had hair exposed. Dietary…
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 · F2026-07-20 · tag F0835 — failed to run the facility competently — widespreadAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
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 personnel records, interviews, and facility policy review, the facility administration failed to effectively administer the facility when they failed to maintain professional standards of practice by falsifying clinical documentation and instructing staff to do the same, thereby compromising the integrity of facility records and resident care. This had the potential to affect 21 residents (Residents #1, #3, #6, #9, #14, #17, #18, #22, #26, #28, #32, #33, #37, #41, #43, #47, #51, #53, #56, #58 and #64), who received blood glucose monitoring. This also had the potential to affect the clinical documentation all 64 residents residing in the facility. The facility census was 64. Findings include:Review of the employee file for the Director of Nursing (DON), hire date of 06/05/26, included her job description. The DON job description, undated, revealed she was responsible for organizing and directing activities in the nursing department to ensure proper resident care. The DON would…
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 · E2026-07-20 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide a safe environment related to potholes in the parking lot. This affected five residents (#23, #25, #28, #44, and #68) of five residents present at the resident council meeting. Additionally, the facility failed to maintain water temperature of sinks and showers at a level a reasonable person would find comfortable. This had the potential to affect the 33 residents (#1, #3, #4, #5, #6, #8, #11, #15, #16, #19, #21, #23, #29, #30, #32, #37, #39, #41, #43, #46, #48, #55, #58, #61, #63, #64, #68, #69, #76, #77, #78, #79, and #80) residing on the 200-unit and 400-unit within the facility. The facility census was 64. Findings include: 1. Review of the quotes to repair the parking lot revealed quotes were received on 09/16/24, 02/25/26, and 03/26/26. On 07/07/26 at 7:53 A.M., an observation of the parking lot in front of the building revealed 10 large potholes. On 07/08/26 at 9:52 A.M., during the resident council meeting during the annual survey, 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.
- Potential for harm · E2026-07-20 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard 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 record review, observation, and interview, the facility failed to maintain resident records in a complete and accurate manner. This affected three residents (#2, #9 and #70) out of 22 residents reviewed for complete and accurate medical records. The facility census was 64. Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 08/08/20. Diagnoses included but were not limited to hemiplegia and hemiparesis, venous insufficiency and non-pressure chronic ulcer of part of right fit and part of right lower leg. Review of the 06/18/26 quarterly Minimum Data Set (MDS) 3.0 for Resident #2 revealed a Brief Interview of Mental Status (BIMS) of 11 which indicated moderate cognitive impairment. Resident #2 was noted to required moderate assistance with bathing. Review of Resident #2' care plan revealed it was last reviewed on 05/12/26 and indicated an activity of daily living self-care performance deficit related to hemiplegia. Interventions included shower two times a week…
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 · D2026-07-20 · tag F0573 — isolatedLet each resident or the resident's legal representative access or purchase copies of all the resident's records.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, interview, and facility policy review, the facility failed to ensure resident medical records were available upon request. This affected one (Resident #72) of one resident reviewed for medical records requests. The facility census was 64.Findings include:Review of the closed medical record for Resident #72 revealed an admission date of 05/07/26 with diagnoses including chronic respiratory failure, heart failure, anxiety and depression. Resident #72 was discharged from the facility on 05/25/26. Interview on 07/08/26 at 11:47 A.M. with Clinical Manager #533 revealed she started in the medical records office on 05/18/26. She stated the previous medical records clerk never provided her information that Resident #72 would like a copy of her medical records.Interview on 07/08/26 at 11:58 A.M. with Licensed Practical Nurse (LPN) #515 revealed she had corresponded with Resident #72's family via email. However, she was unable to provide an email related to the resident or her representative requesting medical records. LPN #515 stated the medical records request could…
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 · D2026-07-20 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure resident's advance directives were accurately reflected in the medical record. This affected one (Resident #80) of 18 residents reviewed for advance directives. The facility census was 64.Findings include:Review of the medical record for Resident #80 revealed an admission date of 07/03/26 with diagnoses including cellulitis (bacterial infection of the skin layers and underlying tissue) and malignant neoplasm of the prostate (cancer). Review of Resident #80's face sheet revealed he was a Do Not Resuscitate Comfort Care Arrest (DNRCCA) which means healthcare staff would provide all life-saving measures until a person's heart or breathing stops.Review of the physician's orders for Resident #80 revealed he had an order for an advance directive of DNRCCA dated 07/04/26. Continued review of Resident #80's medical record revealed no DNRCCA form signed by a physician was present in the electronic medical record or paper chart. Interview on 07/08/26 at 10:18 A.M. with the Director of Nursing (DON) verified there was not 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 · D2026-07-20 · 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 medical record review, review of the facility incident log, interviews, and policy review, the facility failed to ensure an injury of unknown origin was timely reported to the State Agency as required. This affected one resident (Resident #20) of one resident reviewed for self-reported incidents. The facility census was 64.Findings include: Review of the medical record for Resident #20 revealed an admission date of 05/11/22. Diagnoses included but were not limited to encephalopathy, obstructive hydrocephalus, chronic respiratory therapy, moderate protein-calorie malnutrition, hypokalemia and anemia.Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #20 revealed a Brief Interview of Mental Status (BIMS) score of 14 which indicated intact cognition. Resident #20 was noted to use a wheelchair and required maximum assist for upper dressing and rolling left to right. Resident #20 was noted to be dependent for toileting, bathing, lower body dressing, and transfers.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.
- Potential for harm · D2026-07-20 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of the facility incident log, interviews, and policy review, the facility failed to ensure an injury of unknown origin was timely and thoroughly investigated as required. This affected one resident (Resident #20) of one resident reviewed for self-reported incidents. The facility census was 64.Findings include: Review of the medical record for Resident #20 revealed an admission date of 05/11/22. Diagnoses included but were not limited to encephalopathy, obstructive hydrocephalus, chronic respiratory therapy, moderate protein-calorie malnutrition, hypokalemia and anemia.Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #20 revealed a Brief Interview of Mental Status (BIMS) score of 14 which indicated intact cognition. Resident #20 was noted to use a wheelchair and required maximum assist for upper dressing and rolling left to right. Resident #20 was noted to be dependent for toileting, bathing, lower body dressing, and transfers.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.
- Potential for harm · D2026-07-20 · tag F0641 — isolatedEnsure 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 closed record review and interview, the facility failed to complete the resident Minimum Data Set (MDS) assessments accurately. This affected one resident (#74) out of three residents reviewed for resident assessments. The facility census was 64. Findings include:Review of the closed medical record for Resident #74 revealed an admission date of 05/06/26 with diagnoses including congestive heart failure, atrial fibrillation, spinal stenosis, anemia, hypertension, and hyperlipidemia. Resident #74 discharged from the facility on 05/28/26. Review of the discharge planning review assessment dated [DATE] indicated Resident #74 had met her skilled goals and would be discharging to home or community. Review of the Notice of Medicare Non-Coverage (NOMNC) dated 05/21/26 indicated Resident #74's last covered day was 05/27/26. Review of the discharge Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #74 had an unplanned discharge to home or community. Review of the progress note dated 05/28/26 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 · D2026-07-20 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interviews the facility failed to ensure resident care plans were revised to reflect current resident medical changes and preferences. This affected three residents (Residents #20, #45 and #68) of 18 residents reviewed for care plans. The facility census was 64. Findings include:1. Review of the medical record for Resident #20 revealed an admission date of 05/11/22. Diagnoses included but were not limited to encephalopathy, obstructive hydrocephalus, chronic respiratory therapy, moderate protein-calorie malnutrition, hypokalemia and anemia. Review of the 04/08/26 annual Minimum Data Set (MDS) 3.0 for Resident #20 revealed a Brief Interview of Mental Status (BIMS) of 14 which indicated intact cognition. Resident #20 was noted to use a wheelchair and required maximum assist for upper dressing and rolling left to right. Resident #20 was also noted to be dependent for toileting, bathing, lower dressing and transfers.Review of physician orders for Resident #20 revealed a 12/01/25…
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 12 citations
- Potential for harm · Dcited before2026-07-20 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, shower sheets reviews, interviews and facility policy the facility failed to ensure bathing was provided as required. This affected one resident (Resident #2) of two reviewed for bathing. The facility census was 64. Findings include:Review of the medical record for Resident #2 revealed an admission date of 08/08/20. Diagnoses included but were not limited to hemiplegia and hemiparesis, venous insufficiency and non-pressure chronic ulcer of part of right fit and part of right lower leg.Review of the 06/18/26 quarterly Minimum Data Set (MDS) 3.0 for Resident #2 revealed a Brief Interview of Mental Status (BIMS) of 11 which indicated moderate cognitive impairment. Resident #2 was noted to required moderate assistance with bathing.Review of Resident #2's care plan revealed it was last reviewed on 05/12/26 and indicated an activity of daily living self-care performance deficit related to hemiplegia. Interventions included shower two times a week and as needed and indicated Resident #2 was a one-person assist with showers.Review of the facility shower…
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 · D2026-07-20 · 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
Based on observation, record review, and interview, the facility failed to apply ted hose as ordered for Resident #28. This affected one resident (#28) out of one reviewed for edema. The facility census was 64. Findings include:Review of the medical record for Resident #28 revealed an admission date of 11/13/25 with diagnoses including atrial fibrillation, hypertension, type two diabetes mellitus, hyperlipidemia, and obesity. Review of the physician's orders for Resident #28 identified orders for ted hose on in the morning and off in the evening for edema effective 12/09/25. Review of the care plan dated 05/05/26 revealed Resident #28 experienced cardiovascular disease as evidenced by arrhythmia, hypertension, and hyperlipidemia. Interventions included administer medications and treatments as ordered and document side effects if observed initiated 05/05/26, and notify the physician of edema and changes in skin color initiated 05/05/26. Review of the treatment administration record (TAR) for Resident #28 indicated ted hose were applied on the mornings of 07/08/26 and 07/09/26. 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 · D2026-07-20 · 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 medical record review, interview, incident investigation, falls investigation and facility policy the facility failed to ensure a safe transfer for Resident #20, failed to ensure safety was provided during incontinence care for Resident #12, and also failed to ensure a safe smoking environment for Resident #45. This affected three residents (Resident #12, Resident #20, and Resident #45) of three residents reviewed for accidents. The facility census was 64. Findings include: 1. Review of the medical record for Resident #20 revealed an admission date of 05/11/22. Diagnoses included but were not limited to encephalopathy, obstructive hydrocephalus, chronic respiratory therapy, moderate protein-calorie malnutrition, hypokalemia and anemia. Review of the 04/08/26 annual Minimum Data Set (MDS) 3.0 for Resident #20 revealed a Brief Interview of Mental Status (BIMS) of 14 which indicated intact cognition. Resident #20 was noted to use a wheelchair and required maximum assist for upper dressing and rolling left…
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 · D2026-07-20 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation and interview, the facility failed to ensure resident's enteral feedings were administered as ordered. This affected one (Resident #63) of one resident reviewed for enteral nutrition. The facility census was 64. Findings include:Review of the medical record for Resident #63 revealed an admission date of 11/19/25 with diagnoses including respiratory failure, quadriplegia, dysphagia (difficulty swallowing) and dependence on mechanical ventilator. Review of the physician's orders for Resident #63 for July 2026 revealed an order for enteral tube feeding to run at 54 milliliters (mL)/hour for 20 hours dated 06/08/26. Observation on 07/06/26 at 1:37 P.M. of Resident #63 revealed her enteral tube feeding to be running at 45 mL/hour. Observation and interview on 07/06/26 at 2:02 P.M. with Licensed Practical Nurse (LPN) #515 revealed Resident #63's enteral tube feeding was running at 45 mL/hour. LPN #515 verified it was not running at the correct rate per the physician's order. Review of the facility policy titled, Enteral Feeding Policy, dated April 2026,…
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 · D2026-07-20 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
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, interview, and review of facility policy, the facility failed to ensure Resident #9 had physician's orders to receive dialysis treatments and failed to assess Resident #9's condition upon return from dialysis. This affected one Resident (Resident #9) out of one reviewed for dialysis. Findings include:Review of the medical record for Resident #9 revealed an admission date of 05/22/26 with diagnoses including end stage renal disease, hypertension, type two diabetes mellitus, and dependence on renal dialysis. Review of the care plan dated 05/23/26 indicated Resident #28 required hemodialysis related to end stage renal disease. Interventions included provide dialysis as ordered initiated 05/23/26, follow the in-house dialysis schedule initiated 05/23/26, complete the handoff communication form daily initiated 05/23/26, transport to dialysis initiated 05/23/26, and check for bruit and thrill every shift initiated 05/25/26. Review of the admission Minimum Data Set (MDS) assessment dated [DATE]…
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 · D2026-07-20 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure the pharmacy recommendations were addressed by the physician in a timely manner. This affected one resident (Resident #2) of five residents reviewed for unnecessary medications. The facility census was 64.Findings include:Review of the medical record for Resident #2 revealed and admission date of 08/08/20. Diagnoses included but were not limited to hemiplegia and hemiparesis, severe bipolar disorder with psychotic features, anxiety disorder, chronic post traumatic headaches and history of traumatic brain injury.Review of the 06/18/26 quarterly Minimum Data Set (MDS) 3.0 for Resident #2 revealed he required moderate assistance with most activities of daily living and no noted behaviors. Medications included antipsychotic, antidepressant, diuretic, opioid, anticonvulsant and no gradual dose was noted as attempted.Review of the physician orders for Resident #2 revealed an order dated 03/17/23 for one oral capsule of 75 milligrams (mg) of Effexor extended release to be given by mouth two times a day for depression. 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 · D2026-07-20 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure Resident #72 was free of significant medication errors. This affected one (Resident #72) of nine residents reviewed for medications. The facility census was 64. Findings include: Review of the medical record for Resident #72 revealed an admission date of 05/07/26 with diagnoses including chronic respiratory failure, chronic obstructive pulmonary disease, heart failure, anxiety and depression. She was discharged from the facility on 05/25/26. Review of the infectious disease consult dated 05/07/26, Resident #72 was ordered Cresemba 372 milligrams (mg) once daily. Cresemba is an antifungal medication prescribed to treat invasive fungal infections, specifically invasive aspergillosis which is a severe rapidly progressive form that attacks the lungs and can spread to the brain, kidneys and skin and causes symptoms of fever, chest pain, shortness of breath and coughing up blood. Review of the physician's orders for Resident #72 revealed an order for Isavuconazonium Sulfate (Cresemba) 372 mg one time a day 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.
- Potential for harm · D2026-07-20 · 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 record review, observations and interviews, the facility failed to ensure proper infection control standards were maintained during incontinence care and wound care for Residents #10 and #58. This affected two (Residents #10 and #58) of three residents observed for incontinence care and wound care. The facility census was 64. Findings include: 1. Review of the medical record for Resident #10 revealed an admission date of 06/09/23 with diagnoses including peripheral vascular disease, diabetes mellitus, anxiety, chronic kidney disease, cognitive communication deficit, heart failure and polyosteoarthritis. Review the care plan dated 06/12/23 for Resident #10 revealed she had bladder and bowel incontinence. Interventions included for staff to provide good pericare after each episode of incontinence. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #10 had intact cognition. It was documented that she had no behaviors. Resident #10 was dependent on staff 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.
- Potential for harm · Dcited before2026-03-07 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview and facility policy review, the facility failed to ensure activities of daily living were completed for dependent residents. This affected three (Residents #15, 47, and #73) of six residents reviewed for activities of daily living. The facility census was 75.Findings include:1. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE]. Diagnoses included unspecified, spinal stenosis, asthma and scope episodes.Review of the plan of care dated 09/25/25 noted Resident #15 had a self-care deficit with activities of daily living. Interventions included receiving oral hygiene daily and as needed. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had impaired cognition. The resident was dependent on staff for activities of daily living.Review of the activities of daily living tasks for the last 30 days noted staff provided oral care for Resident #15 an average of once a day.2. Review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-10-12 · tag F0761 — failed to label and store drugs safely — patternEnsure 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, staff interview and review of the manufacture storage instructions revealed the facility failed to ensure medication storage guidelines were followed. This affected one Resident (Resident #29) of six residents that received insulin on the 300 unit and had the potential to affect 11 newly admitted residents (Resident #8, #11, #16, #55, #59, #117, #212, #213, #214, #215, #216) requiring Tuberculosis skin testing. The census was 59. Findings Include: 1. Observation on 10/10/23 at 4:54 P.M. of the 300-medication cart with Licensed Practical Nurse (LPN) #261 revealed Resident #29's basaglar kwick pen (long acting) insulin had an expiration date of 12/01/24. The pen had an open date of 09/09/23 that indicated the insulin was open for 32 days, exceeding the recommended 28 days. Interview on 10/10/23 at 4:55 P.M. with LPN #261 verified Resident #29's pen had an opened date of 09/09/23 and had been opened over the recommended 28 day use by date. Review of the facility policy titled Storage of Medication, dated November 2020, revealed discontinued, outdated, or…
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 · D2023-10-12 · tag F0759 — failed to keep medication error rate low — isolatedEnsure 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 maintain a medication error rate of less than five percent (%). Two errors were observed in 27 opportunities resulting in a 7.41% medication error rate. This affected one resident (#14) of four residents observed for medication administration. The census was 59. Finding Include: On 10/11/23 at 8:02 A.M. Licensed Practical Nurse (LPN) #238 was observed administering medications to Resident #14. The LPN prepared multiple medications for the resident, including Novolog (short acting) insulin pen and Toujeo Solo Star (long acting) pen. LPN #238 prepared the Novolog pen by removing the cap of the and wiping the top of the pen with alcohol and applying the needle. She dialed the dosage to 14. LPN #238 prepared the Toujeo pen by removing the cap of the pen, wiping the top of the pen with alcohol, applying the needle and then dialed the dosage to 30 units. The LPN did not prime the pens. LPN #238 administered Resident 14's whole pills and injected the Novolog and Toujeo insulin injections into the resident's left arm.…
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 before2021-07-29 · tag F0761 — failed to label and store drugs safely — widespreadEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to monitor medication storage refrigerators on a daily bases and maintain the refrigerator temperature at the recommended temperature of 36 to 46 degree Fahrenheit (F). The facility also failed to monitor and expose of 13 expired Insyte Autoguards (used to start intravenous lines) that were located in the Intravenous (IV) cart. This had the potential to affect 13 residents (Resident #1, #2, #5, #20, #25, #32, #42, #45, #47, #50, #207, #258, and #261) of 13 residents reviewed for medication storage, with the potential to affect all 53 residents in the facility. Findings include: 1. Observation on [DATE] at 8:30 A.M. of the medication storage room with the Director of Nursing (DON) revealed one medication storage refrigerator was located in the medication storage room. The forms titled, Temperature log for [DATE], [DATE], [DATE] and [DATE] were located on the door of the refrigerator. Interview with the DON at this time verified the temperature…
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.
“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 |
|---|---|---|---|---|
| SANCTUARY HEALTH NETWORK LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 05/18/2015 |
| MERCER, CHARLES | Individual | W-2 MANAGING EMPLOYEE | — | since 05/18/2015 |
| BILLER, FRANK | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 05/18/2015 |
CMS files one row per role, so the 4 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner 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 75% 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 $80K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
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 2026-09-01 — CMS provider number 365428. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-07-20, 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.