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Court House Manor

555 North Glenn Ave, Washington Court Hou, OH 43160 · For profit - Corporation · 99 certified beds · (740) 335-9290 Medicare & Medicaid certified

Call the home — (740) 335-9290 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
2 actual-harm citations1 Medicare payment denial
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
Worth asking about
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its payroll-based staffing rating is low (2/5)

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

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

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

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1510 Columbus Ave · (740) 335-1210 · Call to confirm hours
Pharmacy
1795 Columbus Ave · (800) 746-7287 · Call to confirm hours
Grocery
1151 Columbus Ave · (740) 335-8220 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
525 Glenn Ave · (740) 333-3230

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

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 3 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 4 stars. From monthly CMS archive snapshots.

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

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased5.4%5.3%15.4%typical for the state — see note marked double-dagger below the table
Long-stay residents who lose too much weight6.3%6.2%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.2%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection2.1%0.4%2.0%typical
Long-stay residents with depressive symptoms6.0%30.1%6.5%typical
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury4.2%3.2%3.3%worse
Long-stay residents whose ability to walk worsened3.0%6.1%16.1%better than state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication24.9%25.5%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%94.5%95.3%typical
Long-stay residents with pressure ulcers1.2%3.4%4.7%better
Long-stay residents with worsening bladder/bowel control27.4%21.4%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table2.5%8.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.9%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine82.8%75.6%79.4%typical
Short-stay residents rehospitalized after admission26.9%24.9%22.6%worse
Short-stay residents with an outpatient ER visit19.0%12.9%12.0%worse
Long-stay hospitalizations per 1,000 resident days0.541.731.67better
Long-stay outpatient ER visits per 1,000 resident days1.551.801.80better

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

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

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

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

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

62.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 108 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

62.2%U.S. median 51.5%
Got home and stayed home
14.3%U.S. median 10.7%
Went back to hospital
50.0%U.S. median 56.6%
Met the expected recovery
0.27U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.13hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 50.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 52 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 0.27 therapist hours per resident per day in 2026Q1 — more than 41% of the 13,892 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 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF62.2%CMS range 52.6–70.051.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF14.3%CMS range 10.9–18.910.7%Oct 2022–Sep 2024worse than U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge50.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge42.3%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge50.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified98.6%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.4%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization9.1%CMS range 5.4–15.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.971.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.45
RN hours/ resident / day
1.02
LPN hours/ resident / day
2.07
Aide hours/ resident / day
3.53
Total nurse hours/ resident / day
0.31
RN hoursweekends
42.7%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 99 beds and averages 86.8 residents a day — about 88% 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 3.53 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.45 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.07 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 3.23 hrs/resident/day on weekends vs 3.66 on weekdays — 12% thinner on weekends. RN hours go from 0.50 to 0.31 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 43% is about the same as the national median of 45%.

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

6
deficiencies at the latest standard inspection (2025-03-26)
6
at the previous standard inspection (2022-12-27)

Deficiencies are unchanged from the previous inspection. 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.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

22 citations, most serious first. The 12 most serious are shown; the remaining 10 are one tap away and print in full.

  • Actual harm · Gcited before2024-11-06 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, physician interview, and hospital record review, the facility failed to provide treatment and care in accordance with professional standards of practice when they failed to monitor Resident #2 who was on Eliquis (an anticoagulant medication) and had a decreasing hemoglobin and did not complete a Physician recommended complete blood count (CBC) lab test. This resulted in harm when Resident #2 had bloody tarry stool and was admitted to the hospital for three days with a hemoglobin lab value (a test to detect anemia with a normal range of 11.5 to 15.4 g/dl) of 4.5 grams per dececiliter (g/dl) upon hospital admission. Resident #2 had to receive three units of packed red blood cells and was found to have a gastric ulcer that required clamping. This affected one (Resident #2) of three residents reviewed on anticoagulant medication. The facility census was 88. Findings include: Record review of Resident #2 revealed an admission date of 03/04/22 with pertinent diagnoses…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2019-09-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, hospital record review, observation, staff interview and facility policy review, the facility failed to ensure Resident #33's fall interventions were implemented to prevent falls in accordance with the resident's fall risk care plan. This resulted in actual harm when Resident #33's bilateral side rails were not in place and the resident experienced a fall resulting in a laceration to the head and bruising. The resident was subsequently sent to the hospital and required staples. In addition, the facility failed to ensure staff implemented a second resident's (Resident #32) fall interventions in accordance with the care plan. This affected two (Resident #32 and Resident #33) of four residents reviewed for falls. The facility census was 89. Findings include: 1. Review Resident #33's medical record revealed an admission date of 12/13/17 with diagnoses including unspecified pain, unilateral primary osteoarthritis to the left knee, muscle weakness, difficulty in walking, and cerebral…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-03-26 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on infection control log review and interview, the facility failed to ensure facility and community acquired organism was identified and tracked in the facility's infection control log. This had the potential to affected all 88 residents residing in the facility. Findings Include: Review of the January 2024 infection control log, the urinary tract infection (UTI) no catheter flow tracking sheet revealed Resident #143 was prescribed the antibiotic Augmentin for a UTI with no identification of the organism causing the UTI. Review of the February 2024 infection control log, the UTI no catheter flow tracking sheet revealed Resident #12, #144 and #145 were admitted from the hospital with antibiotic orders with no identifying organism causing the UTI. Review of the March 2024 infection control log, the UTI no catheter flow tracking sheet revealed Resident #38, #144 and #146 were admitted from the hospital with antibiotic orders with no identifying organism causing the UTI. Review of the July 2024 infection control log, the UTI no catheter flow tracking sheet revealed Resident #52,…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-26 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, interview and facility policy review, the facility failed to notify one resident's (#30) family of a change in condition and new physician orders related to the change in condition. This affected one (Resident #30) of 18 sampled residents. The facility census was 88. Findings Include: Review of the medical record for Resident #30 revealed an initial admission date of 01/26/21 with the latest admission date of 03/12/25 with the diagnoses including pneumonia, anemia, adjustment disorder with anxiety and depressed mood, cerebrovascular accident with right sided hemiplegia, severe morbid obesity, chronic obstructive pulmonary disease, hypercholesterolemia, obstructive sleep apnea, obstructive and reflux uropathy, gout, dementia, congestive heart failure, osteoarthritis, metabolic encephalopathy, spinal stenosis, atrial fibrillation, diabetes mellitus, major depressive disorder and insomnia. Review of the plan of care dated 11/18/22, last revised 02/26/24 revealed the resident was at risk for bleeding and bruising due to antiplatelet therapy. Interventions…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-26 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations, record reviews, and hospital discharge record review, the facility failed to ensure Resident #188 had a dressing order in place and [NAME] hose ordered and failed to ensure Resident #199's weekly wound assessments were documented along with daily treatments completed for a surgical wound. Furthermore, the facility also failed to ensure a hospice certification was present for Resident #5. This affected three residents (#5, #188, and #199) of four residents reviewed. The facility census was 88. Findings include: 1. Review of the medical record for Resident #188, revealed an admission date of 03/07/25. Diagnoses included but were not limited to dementia, major depressive disorder, cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, and periprosthetic fracture around internal prosthetic fracture around internal prosthetic right hip joint, subsequent encounter. Review of the functional abilities assessment dated [DATE] for Resident #188…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-26 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview, review of wound notes and facility policy review, the facility failed to prevent facility acquired suspected deep tissue injury (a type of pressure-induced damage to underlying tissues, such as muscle and subcutaneous layers, that appears as a localized area of discolored intact skin (purple or maroon) or a blood filled blister, without a visible open wound) to bilateral heels. This affected one (Resident #188) of three residents reviewed for pressure ulcers. Facility census was 88. Findings include: Review of the medical record for Resident #188, revealed an admission date of 03/07/25. Diagnoses included but were not limited to dementia, major depressive disorder, cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, and periprosthetic fracture around internal prosthetic fracture around internal prosthetic right hip joint, subsequent encounter. Review of the functional abilities assessment dated [DATE] for Resident #188…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-26 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    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 ensure a resident received medication. This affected one (Resident #10) of five residents reviewed for medication administration. The facility census is 88. Findings Include: Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses of dry eye syndrome of bilateral lacrimal glands, bell's palsy, and candidiasis of skin and nails. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #10 had mild cognitive deficit and was frequently incontinent of bowel and always incontinent of bladder. The resident required supervision or touching assistance with eating, partial/moderate assistance with oral hygiene and bed mobility, substantial/maximal assistance for toileting and transfers, substantial/maximal assistance for bathing, partial/moderate assistance for personal hygiene and substantial/maximal assistance for dressing. Review of physician orders…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-26 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and facility medication storage policy, the facility failed to ensure outdated medications were removed from stock. This affected one (Resident #53) out of 11 resident's insulin reviewed. Facility census is 88. Findings include: Review of the medical record revealed Resident #53 was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus with hyperglycemia. Review of the Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #53 had a slight cognitive deficit and was always incontinent of bowel and frequently incontinent of bladder. The resident required independent with eating, set up or clean up assistance with oral hygiene and bed mobility, dependent for toileting and transfers, substantial/maximal assistance for bathing, setup or clean-up assistance for personal hygiene and dependent assistance for dressing. Review of physician orders revealed Resident #53 had an order dated [DATE] to be administered Humalog Kwik insulin pen-injector…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-06 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and record review the facility failed to complete a pressure ulcer dressing change per physicians orders for Resident #79. This affected one (Resident #79) of three residents reviewed for pressure ulcers. The facility census was 88. Findings include: Record review of Resident #79 revealed an admission date of 10/13/24 with pertinent diagnoses of: sepsis, pressure ulcer of sacral region, hypertension, mood affective disorder, local infection of the skin, major depressive disorder, anemia, acquired absence of left leg below the knee, and infection of amputation stump left lower extremity. Review of the 10/18/24 admission Minimum Data Set (MDS) assessment revealed the resident was cognitively intact and used a wheelchair to aid in mobility. The resident required setup or clean up assistance to roll left and right and was independent for sit to lying. The resident was occasionally incontinent of bladder and frequently incontinent of bowel. The resident was at risk for pressure ulcer. Review of a Physician Order dated 10/18/24 revealed wound care…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-06 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and record review the facility failed to to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections when staff did not follow infection control procedures during a dressing change for Resident #79. Facility staff did not follow infection control techniques when they removed Resident #79's soiled dressing and did not change gloves and then cleaned the wound with the soiled gloves. This affected one (Resident #79) of three residents reviewed for pressure ulcers. The facility census was 88. Findings include: Record review of Resident #79 revealed an admission date of 10/13/24 with pertinent diagnoses of: sepsis, pressure ulcer of sacral region, hypertension, mood affective disorder, local infection of the skin, major depressive disorder, anemia, acquired absence of left leg below the knee, and infection of amputation stump left lower extremity. Review of the 10/18/24 admission Minimum Data Set (MDS) assessment revealed the resident was cognitively intact and used a wheelchair to aid…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2022-12-27 · tag F0803 — failed to meet residents' dietary needs — widespread
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observations, review of the facility policy, and staff interview, the facility failed to follow the therapeutic spreadsheet and provide food portions as planned by a registered dietitian. This had to the potential to affect all 78 residents receiving food from the kitchen. The facility census was 78. Findings include: Review of the breakfast menu spreadsheet dated 12/21/22 revealed the breakfast meal consisted of six ounces of hot cereal. Observation on 12/21/22 at 7:30 A.M. revealed Dietary Server #290 on Unit A kitchenette used a four-ounce scoop for all residents who selected hot cereal. Interview on 12/21/22 at 7:45 A.M. with Dietary Server #290 verified she had served four ounces of hot cereal to all residents who selected hot cereal. Dietary Server #290 verified the portion size was to be six ounces as listed on the meal ticket, which was generated by the menu spreadsheet. Observation on 12/21/22 at 7:35 A.M. revealed Dietary Server #320 on Unit C kitchenette used a four-ounce scoop for all residents who selected hot cereal. Interview on 12/21/22 at…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2022-12-27 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, review of facility policy, and staff interview, the facility failed to store foods with label and dates and discard expired foods. This had the potential to affect all 78 residents who received food from the kitchen. The facility census was 78. Findings include: 1. Observation on 12/21/22 at 7:25 A.M. of Unit A kitchenette revealed in the reach in refrigerator, there were two containers of unidentifiable foods with no date and no label. Interview on 12/21/22 at 7:25 A.M. with Dietary [NAME] #321 verified the containers should have been labeled and dated. 2. Observation on 12/21/22 at 7:35 A.M. of Unit B kitchenette revealed in the reach in refrigerator, there was a plastic bag labeled bacon dated 12/11/22. Interview on 12/21/22 at 7:35 A.M. with Dietary Aide #290 verified the containers should have been labeled and dated. 3. Observation on 12/21/22 at 7:45 A.M. of Unit C kitchenette revealed in the refrigerator, there were 15 boiled eggs unlabeled and dated 12/01/22 and there was a plastic bag of labeled swiss cheese dated 12/09/22. Interview on 12/21/22 at…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 10 citations
  • Potential for harm · D2022-12-27 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, review of the facility policy, and record review, the facility failed to ensure residents were provided dignified care related to residents names being visible on the outside of clothing. This affected one (Resident #18) of 24 residents reviewed for dignity. The facility census was 78. Findings include: Review of the medical record for Resident #18 revealed an admission date of 11/19/22. Diagnoses included cerebral infarct and depression. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 had significant cognitive impairment and required extensive assistance of one staff for transfers and dressing. Review of the plan of care dated 12/02/22 revealed Resident #18 had a self care deficit with interventions for dressing to have assistance from one staff person. Observation on 12/19/22 at 10:40 A.M. revealed Resident #18 was seen with his name visible on his socks with what looked like tape. Subsequent observation on 12/20/22 at 10:46…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-27 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, review of the facility policy, and record review, the facility failed to ensure a resident had an updated Preadmission Screening and Resident Review (PASARR). This affected one (Resident #4) of two residents reviewed for PASARR. The facility census was 78. Findings include: Review of the medical record for Resident #4 revealed an admission date of 06/04/12. Diagnoses included borderline personality disorder, post traumatic stress disorder, major depression, and panic disorder. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had moderate cognitive impairment. Review of the plan of care dated 12/15/22 revealed Resident #4 was on several psychotropic medications with history of substance use and mental illness with interventions to monitor medications for side effects, and monitor and document behaviors. Interview on 12/20/22 at 9:00 A.M. with Social Services (SS) #244, the Administrator and the Director of Nursing (DON) verified the facility has no…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-12-27 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based in observation, resident and staff interview and record review, the facility failed to ensure a resident's wound was assessed and monitored after admission. The affected one (Resident #184) of one resident reviewed for non-pressure skin impairments. The facility identified nine residents with non-pressure wounds. The facility census was 78. Findings include: Review of the medical record for Resident #184 revealed an admission date of 12/16/22. Diagnoses included injury of foreign body (bullet), heart disease, type two diabetes mellitus, and hypertension. Review of the admission nursing assessment dated [DATE] revealed Resident #184 had a gun shot wound to the left thigh and redness to the groin. It did not mention significant bruising to the left thigh. There were no details, measurements, or comments left with skin impairment descriptions. Review of the baseline plan of care dated 12/17/22 revealed the plan of care did not include Resident #184's bullet wound or any monitoring or treatment. Review of the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-27 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility policy, observation, interviews of staff and residents, and record reviews, the facility failed to ensure residents with limited range of motion (ROM) received the appropriate treatment and services to increase and/or to prevent a further decrease in ROM. This affected two (Residents #4 and #34) of two residents reviewed for positioning and mobility. The facility identified six current residents with a contracture(s). The facility census was 78. Findings include: 1. Review of the medical record for Resident #4 revealed an admission date of 06/04/12. Diagnoses included hemiplegia and hemiparesis epilepsy, borderline personality disorder, and panic disorder. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had moderate cognitive impairment and required extensive assistance of one for transfers. Resident #4 had an impairment of the upper extremity. Review of the physician order dated 11/03/21 to 12/01/21 and a second order dated 11/29/22 to…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2019-09-12 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and policy review, the facility failed to serve and distribute food under sanitary conditions during dining observation. This had the potential to affect 25 (Resident #3, #10, #11, #13, #20, #24, #28, #32, #35, #38, #40, #43, #45, #46, #48, #49, #50, #53, #56, #57, #61, #67, #71, #74, and #77) residents residing on the A wing. The facility census was 89. Findings include: Observation was conducted on 09/09/19 at 11:16 A.M., of the dining room on A wing. [NAME] #136 was preparing trays to serve in the dining room and she was touching hamburger buns with her bare ungloved hands and was observed pulling up her pants and wiping her hands on her uniform then continued to touch the buns without washing her hands and/or putting on gloves. [NAME] #136 would get the bun out of the package with bare hands, opened up the bun, placed philly steak on the bun then would touch the top bun with her bare hands. [NAME] #136 would then pat the sandwich down touching the top bun with her bare hands. She continued this process with all trays made. Observation was…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2019-09-12 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview and facility policy review, the facility failed to cleanse a blood glucometer machine per manufacture instructions. This had the potential to affect 23 (Resident #2, #8, #9, #13, #20, #30, #31, #32, #39, #42, #46, #54, #58, #60, #66, #67, #69, #83, #88, #140, #141, #142, and #339) residents who require blood glucose monitoring, and failed to ensure Resident #70 who was in contact isolation, had a sign posted on the door to alert staff and visitors to see the nurse for necessary precautions to take before entering the room. This affected one of one residents reviewed under infection precautions area. The facility census was 89. Findings include: 1. Observation of Registered Nurse (RN) #110 on 09/10/19 at 4:22 P.M. revealed the nurse completed a blood glucose fingerstick for Resident #81. RN #110 then cleaned the glucometer with wipes from the top drawer of the cart. Review of the manufactures instructions for the glucometer cleaning Cleaning 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-09-12 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and staff interview, the facility failed to update and revise Resident #32's care plan to reflect use of hoyer lift at times with transfers and failed to update and revise Resident #5's care plan to reflect cleaning techniques for feeding tube. This affected two residents (Resident #32 and Resident #5) of 26 residents reviewed for care plan accuracy. The facility census was 89. Findings include: 1. Review of the medical record for Resident #32 revealed an admission date of 09/12/14 with diagnoses including dementia, anxiety, depression, insomnia, and right leg above knee amputee. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he had moderate cognitive deficits and received extensive assistance of two staff for transfers. Review of September 2019 physician orders revealed there was no order for any mechanical lift for transfers. Review of therapy note dated 08/03/19, 08/05/19, 08/07/19, and 08/09/19 revealed Resident #32 was a hoyer lift…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-09-12 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to provide continuity of care when they did not transcribe three new pain medication orders for a resident following an emergency room visit. This affected one resident (Resident #32) of four residents reviewed for pain . The facility census was 89. Findings include: Review of the medical record for Resident #32 revealed an admission date of 09/12/14 with diagnoses including dementia, anxiety, depression, insomnia, and right leg above knee amputee. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he had moderate cognitive deficits, received routine pain medication, and had no pain. Review of September 2019 physician orders and medication administration record revealed he received Norco two times a day for chronic pain and gabapentin three times a day for pain. There were no other pain medications. Review of daily pain assessments for September 2019 revealed pain was assessed from a score of three to seven (…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-09-12 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure a physicians order was in place for an indwelling urinary catheter (foley) for Resident #85. This affected one (Resident #85) of three residents with catheters in the facility. The facility census was 89. Findings include: Resident #85 was admitted to the facility on [DATE] with diagnoses including a stage four pressure area to the sacral region, Alzheimer's disease, aphasia, dysphasia, delusional disorders, and adult failure to thrive. Review of the physician orders upon admission revealed Resident #85 did not have an order for a Foley catheter. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #85 was severely cognitively impaired. Her functional status was listed as one to two-person extensive assistance for all activities of daily living except locomotion on and off the unit for which she was a total assist. Review of the care plan dated 08/30/19 revealed a plan was in place for Resident #85 with a 16…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-09-12 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and staff interview and facility policy, the facility failed to date and label oxygen tubing for two (Resident #29 and Resident #65) of 28 residents on oxygen therapy. The facility census was 89. Findings include: 1. Review of Resident #29's medical record revealed an admission date of 05/28/19 with diagnoses including diffuse traumatic brain injury with loss of consciousness, occlusion and stenosis of right carotid artery, hypoxemia, and peripheral vascular disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 had long and short term memory deficits. Review of Resident #29's physician order dated 09/06/19 revealed an order for oxygen two to four liters per minute per nasal canal and order dated 09/08/19 revealed to change oxygen tubing every Sunday. Review of Resident #29's progress note dated 09/06/19 revealed an oxygen saturation level of 44-45% on room air and oxygen was applied to increase oxygenation level. Observation 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record. 1 Medicare payment denial on record.

  • Medicare payment denial — starting 2024-11-30 for 20 days

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.

Part of a chain

This home belongs to HCF MANAGEMENT — 22 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 53.1+0.9 vs chain
Health inspection 3 of 52.9+0.1 vs chain
Staffing 2 of 52.8-0.8 vs chain
Quality measures 5 of 54.1+0.9 vs chain
The other 21 homes this chain runs (chain average 3.1★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
CHAD M. UNVERFERTH 12-14-11 IRRV GRANTOR TROrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST6%since 12/13/2021
DAVID V. UNVERFERTH 12-14-11 IRRV GRANTOR TROrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST6%since 12/13/2021
JEFFREY L. UNVERFERTH 12-14-11 IRRV GRANTOR TROrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST6%since 12/13/2021
JOANN C. UNVERFERTH 12-29-04 REVOCABLE TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST5%since 12/13/2021
JOANN C. UNVERFERTH 12-31-12 IRREVOCABLE GRANTOR TRUST FBO KENDRA M. UOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST7%since 12/13/2021
JOANN C. UNVERFERTH 12-31-12 IRREVOCABLE GRANTOR TRUST FBO KERRI A. ROOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST7%since 12/13/2021
JOANN C. UNVERFERTH 12-31-12 IRREVOCABLE GRANTOR TRUST FBO KEVAN R. UNOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST7%since 12/13/2021
JOANN C. UNVERFERTH 12-31-12 IRREVOCABLE GRANTOR TRUST FBO KRISTEN S.Organization5% OR GREATER INDIRECT OWNERSHIP INTEREST7%since 12/13/2021
JOANN C. UNVERFERTH 12-31-12 IRREVOCABLE GRANTOR TRUST FBO KYLE J. UNVOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST7%since 12/13/2021
JOSEPH L. UNVERFERTH 12-15-11 IRRV GRANTOR TROrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST6%since 12/13/2021
LAWRENCE G. UNVERFERTH 12-13-11 IRRV GRANTOR TROrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST6%since 12/13/2021
R. STEVEN UNVERFERTH 12-14-11 IRRV GRANTOR TROrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST6%since 12/13/2021
KLAY, CELESTEIndividualW-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR; CORPORATE OFFICERsince 01/01/2016
ROMES, KERRIIndividualW-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR; CORPORATE OFFICERsince 03/29/2019
SHAW, ANTHONYIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICERsince 06/26/2015
SOUDER, BRITTANYIndividualW-2 MANAGING EMPLOYEE; CORPORATE DIRECTORsince 07/16/2024
UNVERFERTH, CHADIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICERsince 05/01/2008
HCF MANAGEMENT, INC.OrganizationOPERATIONAL/MANAGERIAL CONTROLsince 05/01/2008

CMS files one row per role, so the 25 rows in the source record cover these 18 parties — each is shown once here with every role it holds. Nothing is omitted.

13 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$8.6M
Net patient revenuemost recent cost report
-1.5%
Operating marginrevenue minus expenses
$417K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 64%Medicare 8%Other / private 27%

This home reported $417K 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

$282per resident / day
operating cost
$8,582per month
≈ monthly operating cost
$278per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in OH

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Ohio Medicaid page.

Typical monthly cost in Ohio
$9,186/mo
Nursing home (semi-private)
$10,389/mo
Nursing home (private)
$6,103/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 365928. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-26, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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