Jenkins Care Community
142 Jenkins Memorial Road, Wellston, OH 45692 · Non profit - Corporation · 57 certified beds · (740) 384-2119 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (26% vs 45% nationally) — better care continuity
- it has an abuse, neglect, or exploitation citation (F0600), cited Dec 2024
- it has 1 actual-harm citation
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
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 | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 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 held steady at 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.
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 | 8.6% | 5.3% | 15.4% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 7.8% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.2% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.9% | 0.4% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 2.6% | 30.1% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 9.2% | 3.2% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 12.5% | 6.1% | 16.1% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 25.8% | 25.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.6% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 23.9% | 21.4% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 8.3% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 84.2% | 75.6% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 27.8% | 24.9% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 23.3% | 12.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 0.98 | 1.73 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 3.92 | 1.80 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
61.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 35 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 60.0% 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 30 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 0.36 therapist hours per resident per day in 2026Q1 — more than 60% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 5% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 61.9%CMS range 49.5–74.3 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.2%CMS range 8.3–17.5 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 60.0% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 53.3% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 56.7% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 7.5% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.4%CMS range 4.0–14.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.13 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 57 beds and averages 44.1 residents a day — about 77% occupied, or roughly 13 beds typically open. It usually has some room. 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 3.95 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.41 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.17 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 3.49 hrs/resident/day on weekends vs 4.14 on weekdays — 16% thinner on weekends. RN hours go from 0.45 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 26% is below 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.
23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.
- Actual harm · G2019-11-15 · 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, review of the medical record, facility investigation, staff statements, facility Fall Risk Assessment/Reassessment and Prevention policy and staff interview the facility failed to ensure one resident (Resident #20) was provided assistance with bed mobility by two staff members, as assessed, during incontinence care. Actual Harm occurred when one staff member provided incontinence care to Resident #20 resulting in the resident falling from the bed and sustaining an acute impacted left femoral intertrochanteric fracture (occur when a force presses against both ends of the femur at the femoral neck, pushing the broken ends of the bone together) and unspecified fracture of the lower end of the right femur requiring surgical repair. In addition the facility failed to comprehensively investigate falls to determine trends and implement individualized interventions to prevent falls for Resident #31. This affected two residents (#20 and #31) of four residents reviewed for falls. Findings Include: 1.…
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 before2025-09-19 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and interviews, the facility failed to ensure timely services were provided for a head injury as ordered by the physician, notification to the family of the incident, and ensure fall interventions in place. This affected one (Resident #22) of three residents reviewed for falls. The facility census was 44. Findings include:Record review revealed Resident #22 admitted to the facility on [DATE] with diagnoses including Parkinson's disease, dementia, and fatigue. Review of a care plan dated 11/18/24 revealed Resident #22 was at risk for falls related to deconditioning. The goal was to have less incidents of falls with injuries through the review date. Interventions included but were not limited to anticipate and meet resident's needs, call light in reach, dycem to wheelchair seat, non-skid strips to the floor on the left side of bed, visual cues to remind resident to use call lights, and a safe environment. Review of a physician order from Physician #101 dated 04/10/25 revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-06 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to implement pressure ulcer prevention precautions for Resident #206 identified as having a facility acquired deep tissue injury (DTI) (Purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue). This affected one ( Resident #206) of three residents reviewed for skin impairment. The facility census was 43.Findings include: Review of the closed medical record for Resident #206 revealed an admission date of 02/27/25 and was discharge to the hospital on [DATE]. Resident #206 diagnoses included aftercare following joint replacement surgery, dysphagia, non-rheumatic aortic valve stenosis, left bundle branch block, hypertension, urinary retention and recent gastrointestinal hemorrhage.Review of the Braden scale assessment dated [DATE] revealed Resident #206 was at a high risk for pressure ulcers with a score of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-06 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to maintain a complete and accurate medical record affecting Resident #206. This affected one (Resident #206) of nine resident medical record reviews. The facility census was 43.Findings include:Review of the closed medical record for Resident #206 revealed an admission date of 02/27/25 and was discharged to the hospital on [DATE]. Resident #206 diagnoses included aftercare following joint replacement surgery, dysphagia, non-rheumatic aortic valve stenosis, left bundle branch block, hypertension, urinary retention and recent gastrointestinal hemorrhage. Review of the admission five day Medicare Minimum Data Set (MDS) dated [DATE] revealed Resident #206 was cognitively intact with feelings of depression noted and no behaviors. Resident #206 had impaired range of motion to one side of lower extremities and used a wheelchair for mobility. Resident #206 required a set up for meals and substantial to maximum assistance from staff with toileting hygiene,…
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 · D2025-02-06 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed record review and interviews, the facility failed to provide an appropriate transfer notice with Ombudsman notifications to either the resident or designated representative. This affected one resident (Resident #5) out of three residents reviewed for facility discharge. The facility census was 40. Findings include: Closed Record Review of Resident #5 on 02/04/25 at 11:21 A.M. revealed this resident was admitted to the facility on [DATE] and discharged to the hospital on [DATE] with the following medical diagnoses: chronic kidney disease, GERD, chronic pain, altered mental status, osteoarthritis, fatigue, irritable bowel syndrome, neuralgia and neuritis, gout, hyperglycemia, depression, anxiety, arthritis, shortness of breath, difficult ambulation, and aspirin use. Review of the Minimum Data Set (MDS) assessment completed on 11/26/24 revealed Resident #5 was alert and oriented to name only and had severe cognitive impairment. Review of facility transfer and discharge information revealed 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.
- Potential for harm · D2025-02-06 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 record review and interview, the facility failed to complete a significant change Pre admission Screening and Resident Review (PASARR) for Resident #7 and failed to ensure the admission PASARR was completed accurately for Resident #31. This affected two (Resident #7 and Resident #31) of four residents reviewed for PASARR. The facility census was 40. Findings include: 1. Review of the medical record for Resident #31 revealed an admission date of 11/20/23 with diagnoses including unspecified dementia with psychotic disturbance, diabetes mellitus type two, peripheral vascular disease, visual hallucinations, auditory hallucinations, depressive disorder and bipolar disorder. Review of the physician order dated 11/20/23 revealed Resident #31 was ordered Celexa (antidepressant/antianxiety medication) 20 milligrams (mg) by mouth one time daily for anxiety. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #31 had intact cognition with no mood or behaviors. Resident #31 had diagnosis of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-06 · 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 interview and record review, the facility failed to invite Resident #31 to attend quarterly care conferences. This affected one resident of 12 reviewed for care planning and care conference. The facility census was 40. Findings include: Review of the medical record for Resident #31 revealed an admission date of 11/20/23 with diagnoses including unspecified dementia with psychotic disturbance, diabetes mellitus type two, peripheral vascular disease, visual hallucinations, auditory hallucinations, depressive disorder and bipolar disorder. Review of the physician orders dated 02/25 revealed several changes in medication since Resident #31 was admitted . Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #31 had intact cognition with no mood or behaviors. Resident #31 required partial to moderate assistance from staff to complete activities of daily living. Resident #31 had diagnosis of dementia, depression and bipolar disorder. Resident #31 received antidepressant medication. Review…
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 before2025-02-06 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to provide an ordered psychiatric consult following a gradual dose reduction (GDR) recommendation. This affected one (Resident #35) out of five residents reviewed for unnecessary medications. The facility census was 40. Findings include: Record review of Resident #35 on 02/04/25 at 2:06 P.M. revealed this resident was admitted to the facility on [DATE] with the following medical diagnoses: Parkinson's disease, altered mental status, physical debility, hallucinations, osteoporosis, anxiety, depression, hyperlipidemia, GERD, constipation, dysphagia, edema, depression, and glossodynia. Review of the Minimum Data Set (MDS) assessment completed on 01/22/25 revealed resident was alert and oriented to name only and had minimal cognitive impairment Review of physician orders revealed this resident is receiving the following medications: Venlafaxine 150 milligrams (mg) 1 tablet by mouth twice daily for anxiety; Clozapine 100 mg 1 tablet by mouth daily at bedtime…
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 · D2025-02-06 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure interventions to prevent the worsening of contracture's were implemented. This affected one resident (#7) out of the two residents reviewed for limited range of motion during the annual survey. The facility census was 40. Findings include: Record review for Resident #7 revealed the resident was admitted to the facility on [DATE] and had diagnoses including Parkinsonism, Post Traumatic Stress Disorder (PTSD), and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/21/24, revealed the resident was assessed to have mildly impaired cognition and limited range of motion to bilateral upper extremities. Review of the Occupational Therapy Discharge Progress Note, signed 08/13/24, revealed recommendations skilled Occupational Therapy (OT) services indicated to promote skin integrity and Passive Range of Motion to left hand for application of therapy carrot daily for left hand stiffness. Review of the care…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-06 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure a resident with Post Traumatic Stress Disorder (PTSD) was appropriately assessed to identify causes and triggers for trauma. This affected one resident (#7) reviewed for PTSD during the annual survey. The facility identified one resident having a diagnosis of PTSD. The facility census was 40. Findings include: Record review for Resident #7 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included Parkinsonism, PTSD, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/21/24, revealed the resident was assessed to have mildly impaired cognition. Review of the care plans for Resident #7 revealed there was not a plan of care in place addressing the residents PTSD or trauma. Further record review for Resident #7 revealed there was not an assessment of the cause of the residents PTSD or potential triggers for PTSD. Interview with Social Services employee #105 on 02/05/25 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-06 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary 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 record reviews and interviews, the facility failed to ensure parameters for the monitoring and reporting of hypoglycemia (low blood sugar) were in place. This affected one resident (#31) out of the five residents reviewed for unnecessary medications during the annual survey. The facility census was 40. Findings include: Review of the medical record for Resident #31 revealed an admission date of 11/20/23 with diagnoses including unspecified dementia with psychotic disturbance, diabetes mellitus type two, peripheral vascular disease, visual hallucinations, auditory hallucinations, depressive disorder and bipolar disorder. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #31 had intact cognition with no mood or behaviors. Resident #31 required partial to moderate assistance from staff to complete activities of daily living. Resident #31 had diagnosis of dementia, depression and bipolar disorder. Resident #31 received antidepressant medication and insulin. Review of the physician…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 12 citations
- Potential for harm · Dcited before2025-02-06 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Resident #25 had the appropriate diagnosis for an antipsychotic medication. This affected one (Resident #25) of five residents reviewed for unnecessary medications. The facility census was 40. Findings include: Review of the medical record for Resident #25 revealed an admission date of 12/12/24 with diagnoses including metabolic encephalopathy, unspecified dementia with behavioral disturbance, insomnia, chronic pain, and diabetes mellitus with hyperglycemia. Review of the physician orders dated 02/25 revealed Resident #25 was ordered and received Risperdal 0.5 milligrams (mg) by mouth at bedtime for unspecified dementia with other behavioral disturbance. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #25 had moderate cognitive impairment with disorganized thinking. Resident #25 had physical behavioral symptoms, verbal behavioral symptoms, rejection of care and wandering. Resident #25 required partial to moderate…
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 · D2024-12-26 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, review of the facility Self-Reported Incident (SRI), and policy review, the facility failed to prevent physical abuse for one resident (#10) of three residents reviewed. The facility census was 48. Findings include: Review of the medical record for Resident #10, revealed an admission date of 04/08/22. Diagnoses included but were not limited to unspecified dementia, anxiety disorder, major depressive disorder, muscle weakness, and mood disorder due to known physiological condition. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 07 out of 15 indicating severe cognitive impairment. The resident was assessed to require substantial/maximal assistance with shower/bathe self, bed mobility, transfers and total dependence with toilet hygiene. This resident was also assessed to have skin tears under skin conditions. Review of the SRI dated 11/12/24 revealed an allegation of neglect that occurred on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2019-11-15 · tag F0550 — failed to protect resident dignity and rights — patternHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and staff interview the facility failed ensure residents who resided on the secured dementia unit were provided the necessary utensils to assist with independent meal consumption resulting in a potential undignified dining experience for the residents on the unit. This affected 13 residents (#20, #39, #22, #7, #17, #31, #15, #44, #13, #29, #2, #38 and #21) 13 residents who resided on the secured dementia unit. The facility census was 57. Findings Include: On 11/12/19 at 11:34 A.M. observation of the lunch meal revealed Resident #20, #39, #22, #7, #17, #31, #15, #44, #13, #29, #2, #38 and #21 were served only a spoon and a fork with their meal. The residents were not provided with a knife. At 12:00 P.M. State Tested Nursing Assistant (STNA) #189 was observed to cut Resident #39's hamburger in half using a fork and a spoon. STNA #189 had to remove the tomato from the hamburger in order to cut it, cut the hamburger and then returned the tomato to it. On 11/12/19 at 5:24 P.M. observation of the evening meal revealed Resident #20, #39, #22, #7, #17, #31, #15, #44,…
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 · E2019-11-15 · tag F0656 — failed to write and follow a full care plan — patternDevelop 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 3. Review of Resident # 17's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia without behavioral disturbance, senile dementia, major depression recurrent, anxiety disorder, macular degenerations, type two diabetes, femur fracture and peripheral vascular disease. Resident #17 resided on the secure care unit (SCU). Review of Resident #17's activity assessment, dated 07/07/15 revealed her past and present interests were card games, bingo, outdoors, television, music, religious, van outings, arts and crafts, reading, and discussion. Resident #17 wanted to walk and stay busy during the day. Record review revealed Resident #17 did not have a plan of care for activities. Review of Resident #17's annual MDS 3.0 assessment, dated 03/13/19 revealed her speech was clear she understands others, was understood and her cognition was severely impaired. Resident #17 had no behaviors, did not reject care, and wandered daily. Review of Resident # 17's activity…
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 · E2019-11-15 · tag F0679 — failed to provide activities — patternProvide activities to meet all resident's needs.
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 develop and implement a comprehensive activities program designed to meet the total care needs of all residents. This affected five residents (#15, #17, #20, #21 and #22) of nine sampled residents reviewed for activities. Findings Include: 1. Review of Resident # 17's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia without behavioral disturbance, senile dementia, major depression recurrent, anxiety disorder, macular degenerations, type two diabetes, and femur fracture, and peripheral vascular disease. Resident #17 resided on the secure care unit (SCU). Review of Resident #17's activities assessment, dated 07/07/15 revealed her past and present interests were card games, bingo, outdoors, television, music, religious, van outings, arts and crafts, reading, and discussion. Resident #17 wanted to walk and stay busy during the day. Record review revealed Resident #17 did not have…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2019-11-15 · tag F0758 — failed to limit and justify psychotropic drugs — patternImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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 residents had adequate indication for the use of psychotropic medications and/or failed to ensure the justified use of an as needed (PRN) antipsychotic medication for greater than 14 days. This affected four residents (#21, #22, #31 and #197) of five residents reviewed for unnecessary medication use. Findings Include: 1. Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included pneumonia, delusional disorder, glaucoma, essential hypertension, abnormal weight loss, dementia with behavioral disturbance, major depressive disorder, hypothyroidism and malignant neoplasm of female breast. Review of Resident #21's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident's speech was clear, she understood, understands, and her cognition was severely impaired. Resident #21 had minimal depression, no indicators of psychosis, no behaviors, did not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-11-15 · 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 observation, record review and interview the facility failed to ensure care plans were revised for Resident #31 related to pain management, Resident #20 related to mobility devices and for Resident #197 related to Hospice services. This affected three residents (#31, #20 and #197) of 21 sampled residents whose care plans were reviewed. Findings Include: 1. Review of Resident #31's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, anorexia, mood disorder, hyperlipidemia, bradycardia, heart failure, osteoarthritis, essential hypertension, hypocalcemia, anemia and falls. Review of Resident #31's admission Minimum Data Set (MDS) 3.0 assessment, dated 02/14/19 revealed the resident's speech was clear, he usually understands, usually understood others, and his cognition was severely impaired. Per the assessment, Resident #31 was on scheduled pain medication and he was not in pain. Resident #31 did not reject care.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-11-15 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure Resident #21 and Resident #22 were provided the necessary care and services to maintain the resident's dining ability, ability to eat independently. This affected two residents (#21 and #22) of four residents reviewed for activities of daily living (ADL) care. Finds Include: 1. Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included pneumonia, delusional disorder, glaucoma, essential hypertension, abnormal weight loss, dementia with behavioral disturbance, major depressive disorder, hypothyroidism,and malignant neoplasm of female breast. Review of Resident #21's plan of care, dated 02/20/19 revealed to assist her as needed with her activities of daily living. Review of Resident #21's Minimum Data Set (MDS) 3.0 assessment, dated 02/26/19 and 09/21/19 revealed her speech was clear, she was understood, she understands, and her cognition was severely impaired.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-11-15 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview the facility failed to ensure Resident #15 and Resident #31, who were dependent on staff for activities of daily living received timely and adequate assistance with dressing and personal hygiene. This affected two residents (#15 and #31) of four reviewed for activities of daily living. Findings Include: 1. Review of Resident #15's medical record revealed an admission date of 08/20/19 with the admitting diagnoses of anxiety, dementia and depression. Review of the resident's plan of care, dated 08/21/19 revealed the resident had a self-care performance deficit related to Alzheimer's disease progression. Interventions included to set-up supplies for care and assist with activities of daily living. Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 08/28/19 revealed the resident had clear speech, usually understands others, makes himself understood and had a severe cognitive deficit as indicated by a Brief Interview for Mental…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-11-15 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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, record review and interview the facility failed to ensure Resident #31's oxygen tubing and humidification/water bottle were dated. This affected one resident (#31) of one resident reviewed for oxygen therapy. The facility identified seven residents received respiratory care. Findings Include: Review of Resident #31's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, anorexia, mood disorder, hyperlipidemia, bradycardia, heart failure, osteoarthritis, essential hypertension, hypocalcemia, anemia and falls. Review of Resident #31's admission Minimum Data Set (MDS) 3.0 assessment, dated 02/14/19 revealed the resident's speech was clear, he usually understands, usually understood others, and his cognition was severely impaired. Resident #31 did not reject care. Resident #31 required extensive assistance of one staff for personal hygiene. The assessment revealed Resident #31 did not use oxygen. Review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-11-15 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to implement a comprehensive and individualized pain management program for Resident #31. This affected one resident (#31) of one resident reviewed for pain. Findings Include: Review of Resident #31's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, anorexia, mood disorder, hyperlipidemia, bradycardia, heart failure, osteoarthritis, essential hypertension, hypocalcemia, anemia and falls. Review of Resident #31's plan of care, dated 02/08/19 revealed it did not address non-verbal expressions of pain. Review of Resident #31's admission Minimum Data Set (MDS) 3.0 assessment, dated 02/14/19 revealed the resident's speech was clear, he usually understands, usually understood others, and his cognition was severely impaired. The assessment revealed Resident #31 was on scheduled pain medication and he did not have any pain. Resident #31 did not reject care.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-11-15 · 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 — the official record, unedited, may be distressing
Based on record review and interview the facility failed to ensure Resident #197's medical record was accurate to reflect the discontinuation of Hospice services. This affected one resident (#197) of 24 residents whose medical records were reviewed. Findings Include: Review of the medical record for Resident #197 revealed an admission date of 11/01/19 with diagnoses of dementia without behavioral disturbances, hypertension and anxiety. Review of the progress notes for Resident #197 revealed multiple notes including notes on 11/12/19, and 11/13/19 revealing the resident was receiving Hospice services. Interview on 11/13/19 at 4:10 P.M. with Assistant Director of Nursing (ADON) #154 revealed Resident #197 was discharged from Hospice on 11/05/19. However, nursing staff continued to document the resident was receiving Hospice services after this date.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| ERVIN, GREGORY | Individual | CORPORATE DIRECTOR | since 10/15/2002 |
| FULKS, DAN | Individual | CORPORATE DIRECTOR | since 01/01/2024 |
| FURBEE, MICHELE | Individual | CORPORATE DIRECTOR | since 01/01/2024 |
| HAYES, RONALD | Individual | CORPORATE DIRECTOR | since 10/01/2003 |
| HOLZAPFEL, BONNIE | Individual | CORPORATE DIRECTOR | since 05/01/2017 |
| MASSIE, MARTHA | Individual | CORPORATE DIRECTOR | since 07/01/2000 |
| POTTER, WILLIAM | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/03/2013 |
| SIMMONS, JEFF | Individual | CORPORATE DIRECTOR | since 06/01/2021 |
| NICHOLS, DAVID | Individual | CORPORATE OFFICER; ADP OF THE SNF | since 07/01/2001 |
| JUSCHKA, DIRK | Individual | ADP OF THE SNF | since 05/01/2022 |
CMS files one row per role, so the 14 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
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.
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 365431. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-02-06, 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.