White Oak Manor
1926 Ridge Avenue, Warren, OH 44484 · For profit - Corporation · 52 certified beds · (330) 369-4672 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (17) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $3,282 in federal fines (most recent 2023-12-26)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
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) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 3 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 | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 2 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 | 5.4% | 5.3% | 15.4% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 0.9% | 6.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.2% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.4% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 41.5% | 30.1% | 6.5% | worse 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 | 0.8% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 3.5% | 6.1% | 16.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 27.4% | 25.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 97.0% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 9.0% | 3.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 3.3% | 21.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 6.9% | 8.8% | 17.1% | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Staffing
How full it usually is: this home is certified for 52 beds and averages 28.6 residents a day — about 55% occupied, or roughly 23 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.30 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.42 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.06 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 3.05 hrs/resident/day on weekends vs 3.40 on weekdays — 10% thinner on weekends. RN hours go from 0.51 to 0.19 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 48% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
17 citations, most serious first. The 11 most serious are shown; the remaining 6 are one tap away and print in full.
- Immediate jeopardy · J2025-10-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, review of a facility self-reported incident (SRI) investigation, review of police reports, review of the Emergency Medical Services (EMS) run report, review of hospital documentation, review of facility policy, and interviews, the facility failed to provide adequate supervision to prevent Resident #16, who was cognitively impaired, aphasic and at risk for elopement (with use of a WanderGuard device) from eloping. This resulted in Immediate Jeopardy and the potential for Actual Harm, serious physical injury or death on [DATE] when 911 dispatch for the local police department received a 911 call from a passerby in the community with concerns for an unattended individual. The individual, identified to be Resident #16 was found by the police, coming out of the woods and falling into a ditch in a residential area that was 0.6 miles from the facility. The resident was noted to be confused and wearing a monitor device on his ankle which prompted the police to check with the facility…
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 · F2026-04-22 · tag F0921 — failed to keep a safe, functional, sanitary building — widespreadMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and policy review, the facility failed to maintain a comfortable homelike environment in good repair. This had the potential to affect all 32 residents residing in the facility. The census was 32. Findings include:1. Observation on 04/21/26 at 10:45 A.M. revealed three burnt out ceiling hallway lights from room [ROOM NUMBER] until the end of the 300-hallway. The end of the hallway was darker than the rest of the hallway. Interview with Licensed Practical Nurse (LPN) #447 and Maintenance Director #417 at the time of the observation confirmed the three burnt out ceiling lights starting outside room [ROOM NUMBER] and extending to the end of hallway 300, making the end of the hallway darker than the rest of the hallway. 2. Observations on 4/22/26 between 9:06 A.M. to 9:20 A.M. during a tour with the Administrator revealed a hole, approximately three inches in diameter the wall on the left of the reception window, dark scuff marks across on the Administrator's door, scuff marks…
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 · E2026-01-28 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility policy, the facility failed to ensure medications were stored in a safe and secure manner when the medication cart was left unlocked in the facility. This had the potential to affect 20 residents (#1, #2, #3, #4, #5, #7, #8, #9, #10, #11, #13, #14, #15, #17, #19, #20, #22, #23, #24, and #25) residing in the facility, as the facility identified nine residents as immobile (Residents #6, #12, #16, #18, #21, #26, #27, #28, and #29). Also, the facility failed to ensure medications were not removed from original labeled packaging and pre-poured prior to administration to residents. This affected four residents (Resident #1, #7, #8 and #16) of four residents reviewed for medication administration. The facility census was 29. Findings include: 1. On 01/28/26 at 8:55 A.M., an observation revealed a medication storage cart labeled 100/300 Halls was unlocked. The medication cart was located in an open hallway in front of the nurses' station…
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 · F2025-05-08 · tag F0882 — widespreadDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
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 infection preventionist (IP) role was conducted by a nurse who worked at least part-time in the facility. This had the potential to affect all 34 residents who resided in the facility. Findings include: Review of the Facility Assessment form dated 06/21/24 revealed the assessment did not designate the amount of hours that were required for the IP to be in the facility to ensure implementation of the infection control programs and activities. Review of the IP Training Plan Proof of Completion form dated 05/30/23 revealed Registered Nurse (RN) Regional #851 was the current IP for the facility. Interview on 05/06/25 at 12:10 P.M. with the Administrator revealed RN Regional #851 was the current IP who was in the building once monthly. Interview on 05/06/25 at 12:25 P.M. with RN Regional #851 confirmed she currently completed the IP role once monthly in the facility. The previous staff member who was the IP no longer worked in the building as of 11/15/24. Review of the Infection Prevention and Control Program revised…
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 · D2025-05-08 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure medication administration bags were secured and resident names and medications were not readily visible in the common trash. This affected three (Residents #15, #27 and #136) of four residents reviewed for privacy. Findings include: Review of Resident #15's medical record revealed the resident was admitted on [DATE] with diagnoses including schizoaffective disorder bipolar type, muscle weakness and difficulty in walking. Review of Resident #15's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #27's medical record revealed the resident was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, muscle weakness and heart failure. Review of Resident #27's MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #136's medical record revealed the resident was readmitted on [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 · D2025-05-08 · 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 record review, policy review, and interviews the facility failed to ensure care planning conferences were completed quarterly. This affected two (Residents #24 and #26) of two residents reviewed for development of care plans. Facility census was 34. Findings include: 1. Review of Resident #24's medical record revealed an admission date of 07/07/23 with diagnoses of severe dementia with other behavioral disturbances, schizophrenia, intermittent explosive disorder, and anxiety. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 had moderate cognitive impairment and required supervision for oral hygiene, showers, and personal hygiene. Review of the care planning conferences for Resident #24 from July 2023 to April 2024 revealed conferences were held 11/06/23, 01/17/24, 04/03/24, and 04/24/25. Further review of the care planning conferences revealed the Social Service Designee (SSD) #820 and Assistant Director of Nursing #802 were the members 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 · D2025-05-08 · tag F0770 — failed to provide lab services — isolatedProvide timely, quality laboratory services/tests to meet the needs of residents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure Resident #1's laboratory bloodwork was completed per the physician orders. This affected one (Resident #1) of two residents reviewed for laboratory services. Findings include: Review of Resident #1's medical record revealed the resident was readmitted on [DATE] with diagnoses including schizoaffective disorder bipolar type, chronic obstructive pulmonary disease and cardiomyopathy. Review of Resident #1's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #1's physician orders revealed an order dated 04/04/25 (discontinued 05/06/25) to obtain a potassium level weekly. Review of Resident #1's laboratory bloodwork revealed the potassium level was obtained on 04/04/25, 04/11/25 and 05/02/25. The potassium bloodwork was not obtained on 04/18/25 and 04/25/25 as ordered. Interview on 05/07/25 at 8:30 A.M. with the Director of Nursing (DON) confirmed Resident #1's potassium…
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 · D2025-05-08 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure Resident #1's food preferences were followed during meals. This affected one (Resident #1) of four residents reviewed for food and drink. Findings include: Review of Resident #1's medical record revealed the resident was readmitted on [DATE] with diagnoses including schizoaffective disorder bipolar type, chronic obstructive pulmonary disease and difficulty in walking. Review of Resident #1's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #1's nutrition care plans revealed an intervention dated 02/26/16 to provide diet as ordered. Review of Resident #1's physician orders revealed an order dated 11/19/24 for a regular diet, regular texture with a regular-thin consistency. Resident #1's physician orders did not have an order for Boost or chocolate milk. Interview with Resident #1 on 05/05/25 at 8:45 A.M. revealed she was supposed to have Boost on her meal tray and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-20 · 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 medical record review and staff interview, the facility failed to obtain an electrocardiogram (EKG) services per physician orders for Resident #36. This affected one resident (#36) of three residents reviewed for change in condition. The facility census was 32. Findings include: Review of the closed medical record of Resident #36 revealed an admission date of 02/06/25. Medical diagnoses included acute respiratory failure, nonrheumatic aortic valve insufficiency, metabolic encephalopathy, hypothyroidism, disorder bilirubin metabolism, edema, congestive heart failure, panic disorder, hepatic failure, atherosclerotic heart disease, jaundice, acute myocardial infarction, presence of coronary angioplasty, Turner's syndrome (a chromosomal disorder in which a female is born with only one X chromosome), and abnormal electrocardiogram (EKG). Review of the Minimum Data Set (MDS) 3.0 assessment for Resident #36 dated 02/07/25 revealed the resident's cognition was moderately impaired, and she was dependent upon staff to roll left to right in bed, toileting, hygiene, and bathing. She…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-08 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and facility policy review, the facility failed to implement their abuse policy regarding thoroughly investigating and failing to submit a self-reported incident (SRI) to the state agency of an allegation of staff-to-resident verbal abuse for Resident #2. This affected one resident (#2) of three residents reviewed for abuse. The facility census was 34. Findings include: Review of the medical record revealed Resident#2 was admitted to the facility on [DATE] with diagnoses including depression, anxiety, morbid obesity, and a need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #2 was cognitively intact. Review of the care plan dated 03/25/24 revealed Resident #2 had an activity of daily living (ADL) deficit and required the assistance of one to two staff to complete bathing, toileting and grooming. The care plan also revealed Resident #2 can display accusatory and paranoid behaviors and refused 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 · D2024-05-08 · 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 record review, interview and facility policy review, the facility failed to report an allegation of staff-to-resident verbal abuse to the state agency for Resident #2. This affected one resident (#2) of three residents reviewed for abuse. The facility census was 34. Findings include: Review of the medical record revealed Resident#2 was admitted to the facility on [DATE] with diagnoses including depression, anxiety, morbid obesity, and a need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #2 was cognitively intact and had verbal behaviors one to three times in the seven day look back period. Review of the care plan dated 03/25/24 revealed Resident #2 had an activity of daily living (ADL) deficit and required the assistance of one to two staff to complete bathing, toileting and grooming. The care plan also revealed Resident #2 can display accusatory and paranoid behaviors and refuses for certain staff to be in her room.…
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 6 citations
- Potential for harm · Dcited before2024-05-08 · 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 record review, interview and facility policy review, the facility failed to thoroughly investigate an allegation of staff-to-resident verbal abuse for Resident #2. This affected one resident (#2) of three residents reviewed for abuse. The facility census was 34. Findings include: Review of the medical record revealed Resident#2 was admitted to the facility on [DATE] with diagnoses including depression, anxiety, morbid obesity, and a need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #2 was cognitively intact. Review of the care plan dated 03/25/24 revealed Resident #2 had an activity of daily living (ADL) deficit and required the assistance of one to two staff to complete bathing, toileting and grooming. The care plan also revealed Resident #2 can display accusatory and paranoid behaviors and refuses for certain staff to be in her room. Interventions included allow resident to discuss feelings, approach and speak to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-07 · 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 record review, observation and interview, the facility failed to thoroughly investigate an alleged physical altercation between Resident #5 and Resident #15 in order to take appropriate corrective action. This effected two residents (Resident #5 and Resident #15) of five residents reviewed for abuse. The facility census was 33. Findings include: Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with medical diagnoses including movement disorder, dementia, chronic obstructive pulmonary disease, schizoaffective disorder and anxiety. Review of the Minimum Data Set ( MDS) 3.0 assessment dated [DATE] revealed Resident #5 had moderate cognitive impairment. Resident #5 was independent to roll in bed, sit to lie flat on the bed, lie to sit on side of the bed and sit to stand. Resident #5 required moderate assistance to walk ten feet. Review of the Plan of Care dated 11/17/22 revealed Resident #5 was a risk for problematic behavior and not easily redirected. Resident #5 had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-12-07 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review the facility did not ensure Resident #11 had a physician order and/ or care plan for the use of ankle foot orthosis (AFO) to the bilateral lower extremities per therapy recommendation. This affected one resident (Resident #11) of one resident (Resident #11) reviewed for a splinting device. This had the potential to affect two residents (Residents #10 and #11) with recommendations for a splinting device. Findings include: Review of the medical record for Resident #11 revealed an admission date of 07/27/20 with diagnoses including osteoarthritis, difficulty walking, muscle wasting with atrophy, split foot (birth defect that consists of missing toes), and major depression. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #11 had impaired cognition. He was independent with bed mobility, transfers, and locomotion. He required limited assist of one staff with dressing. He was unable to ambulate. 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 · D2022-12-07 · tag F0804 — failed to serve food at safe, palatable temperature — isolatedEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure pureed foods were the correct consistency and served at an appetizing temperature. This affected two residents (Resident #10 and Resident #19) of 27 residents who received food from the facility. The facility census was 27. Findings include: Interview and observation on 12/04/22 at 8:57 A.M. with Resident #10 revealed the resident had received a pureed breakfast tray. Resident #10 did not eat the items provided and indicated they didn't taste good. Observation of a test tray on 12/05/22 at 12:52 P.M., tested after all residents had been served and were eating, revealed the pureed Chicken [NAME] was 117 degrees Fahrenheit (F). It had good flavor, was the correct consistency, but was not hot enough. The pureed rice was 125 degrees F, had good flavor, but was not a smooth enough consistency for puree. The pureed squash was 147 degrees F. It was hot enough, but bland and lumpy. Interview on 12/05/22 at 12:58 P.M. with Corporate Dietitian #639 and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-12-07 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, interview, and policy review the facility did not ensure accurate medication administration records for Residents #8, #21 and #22. This affected three residents (Residents #8, #21 and #22) of five residents reviewed for unnecessary medications. The facility census was 27. Findings include: 1. Review of the medical record for Resident #8 revealed an admission date of 02/23/21. Diagnoses included cerebral ischemia, diabetes mellitus (DM) type 2, schizoaffective disorder bipolar type, chronic kidney disease stage 3, epilepsy and epileptic syndromes with complex partial seizures, gastroesophageal reflux disease (GERD), hypertension, hyperlipidemia, major depressive disorder, anxiety disorder, and delusional disorder. Review of Resident #8's medication administration record (MAR) for October 2022 revealed the following medications were not documented as administered: • Atorvastatin (medication to treat high cholesterol) 10 milligrams (mg) daily at bedtime for hyperlipidemia (high cholesterol) on 10/08/22 at hs 2 (from 6:00 P.M. to 10:00 P.M.) • Lamotrigine…
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 · E2022-06-02 · tag F0908 — failed to keep essential equipment working — patternKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview the facility failed to ensure the central air conditioning condenser servicing the main dining room, activity area, and hallways was maintained in good working order. This had the potential to affect 24 of 31 residents who ate meals, attended activities and utilized the common areas. Seven residents, Residents #6, #14, #15, #17, #22, #26 and #28, were not affected as they choose to stay in their rooms for meals/activities. Findings include: Interview on 05/31/22 at 10:30 A.M. with Maintenance Director #803 indicated the building was hot by the dining room. He verified he did not routinely monitor temperatures in resident areas or maintain temperature logs. Maintenance Director #803 verified they did not have any temperature measuring device to monitor air temperatures in the facility. He confirmed each individual resident room had their own resident controlled wall mount air conditioning unit and they were all functioning appropriately. Maintenance Director #803 said the air conditioning condenser located outside of the building controlled the air…
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
$3,282 in federal fines across 1 penalty.
- $3,282 — penalty dated 2023-12-26
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| WARREN ASSOCIATES LIMITED PARTNERSHIP | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 06/01/2022 |
| LIONS PRIDE TRUST U/A/D 09/30/2009 | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 94% | since 06/01/2022 |
| HAEGER, KENT | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 6% | since 06/01/2022 |
| GOLD, BRAD | Individual | W-2 MANAGING EMPLOYEE; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 06/01/2022 |
| EMBASSY HEALTHCARE MANAGEMENT INC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 06/01/2022 |
CMS files one row per role, so the 7 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.
3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OH
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Ohio Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 365748. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-08, 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.