Green Hills Center
6557 Us 68 South, West Liberty, OH 43357 · Non profit - Other · 74 certified beds · (937) 465-5065 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- it has an abuse, neglect, or exploitation citation (F0600), cited Sep 2024
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (16) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $16,801 in federal fines (most recent 2024-01-22)
- 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 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 | 4 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.
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 | 4.6% | 5.3% | 15.4% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 5.4% | 6.2% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.2% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.4% | 0.4% | 2.0% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 25.3% | 30.1% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 5.0% | 3.2% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 5.6% | 6.1% | 16.1% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 29.5% | 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 | 3.7% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 27.8% | 21.4% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 10.9% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.6% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 87.1% | 75.6% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 15.9% | 24.9% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 16.9% | 12.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.54 | 1.73 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 2.37 | 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.
57.5% 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 88 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 55.7% 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 61 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 0.48 therapist hours per resident per day in 2026Q1 — more than 79% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 7% 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
| 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 | 57.5%CMS range 48.6–65.9 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.4%CMS range 7.2–14.1 | 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 | 55.7% | 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 | 44.3% | 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 | 39.3% | 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 | 93.8% | 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 | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this 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 | 1.2% | 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 | 2.5% | 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 | 6.8%CMS range 3.3–12.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.96 | 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 74 beds and averages 72.6 residents a day — about 98% occupied, or roughly 1 bed typically open. It runs essentially full — expect a waiting list. 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 0.57 is at or above 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 3.16 hrs/resident/day on weekends vs 3.67 on weekdays — 14% thinner on weekends. RN hours go from 0.64 to 0.41 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
16 citations, most serious first. The 11 most serious are shown; the remaining 5 are one tap away and print in full.
- Immediate jeopardy · Kcited before2024-01-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 observations, staff interviews, medical record review, review of Joerns Hoyer user instruction manual and Invacare patient slings operator's manual, review of the facility's Self-Reported Incident (SRI) and investigation including witness statements, review of the emergency medical services (EMS) report, review of hospital documentation, review of the facility policies on transfer, mechanical lifts, and the mechanical lift checklist, the facility failed to ensure a resident requiring transfers with a mechanical lift was transferred safely. This resulted in Immediate Jeopardy when Resident #15 experienced serious life-threatening injuries during an avoidable fall from a mechanical lift when the lift pad was incorrectly placed on the Hoyer lift and only one-person assisted in the transfer, resulting in a head injury, and severe fractures of the left lower leg which subsequently required an above the knee amputation of the left lower leg. This affected one (Resident #15) of three residents reviewed for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-09-11 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident interview, staff interview, and policy review the facility failed to ensure care conferences were conducted quarterly. This affected four (#12, #38, #39, and #51) of four residents reviewed for care conferences. The facility census was 67. 1.Review of medical record for Resident #12 revealed an admission date of 04/29/25 with diagnoses including but not limited to type two diabetes, congestive heart failure, chronic atrial fibrillation, and major depressive disorder. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 was cognitively intact. Review of care conference notes revealed the last care conference was held on 11/19/24 and only two members of the interdisciplinary team (IDT) were present. 2.Review of Resident #38's medical record revealed an admission date of 12/18/24, diagnoses included cerebral infarction, fistula of stomach and duodenum, ventral hernia, atrial fibrillation, acute gastric ulcer with perforation, type 2 diabetes, dysphagia,…
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 · D2025-09-11 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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 record review, observation, interview, and policy review the facility failed to ensure resident dignity when giving insulin injections. This affected one (#39) resident of one resident reviewed for insulin injections. The facility census was 67.Review of medical record for Resident #39 revealed an admission date of 08/26/22 with diagnoses including type two diabetes, dementia, and major depressive disorder.Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had moderate cognitive impairment.Review of current physician orders revealed an order initiated on 09/08/25 following the observation in the dining room indicating may give medications, check blood sugar and give insulin in public spaces and dining room.Observation on 09/08/25 at 11:22 A.M. of Registered Nurse (RN #360) revealed the nurse came up to Resident #39 sitting at a table in the dining room and informed the resident she had her insulin to administer. RN #360 proceeded to lift the resident's shirt and administer…
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 · D2025-09-11 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
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 policy review the facility failed to ensure residents were provided written bed hold notices. This affected two (#75 and #78) of three reviewed for hospitalizations. The facility census was 67. 1. Review of Resident #75 medical record revealed an admission date of 6/10/25, diagnoses included acute and chronic respiratory failure with hypoxia, atrial fibrillation, heart failure, hypo-osmolality and hyponatremia, chronic lymphocytic leukemia of B-cell, atherosclerotic heart disease, chronic obstructive pulmonary disease, hypertension, and cerebral infarction. Review of Resident #75's Minimal Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, required partial assistance with activities, and required a wheelchair for ambulation. Review of Resident #75's care plan dated 6/10/25 revealed the resident was at risk for alteration in their respiratory status related to chronic obstructive pulmonary disease. Interventions included to monitor for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-11 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review the facility failed to ensure wounds were assessed weekly for Resident #67, and the facility further failed to ensure treatments were in place and completed per physician order for Resident #52. This affected two (#67 and #52) residents of three residents reviewed for wounds. The facility census was 67. 1.Review of medical record for Resident #67 revealed an admission date of 01/19/25 with diagnoses including but not limited to acute transverse myelitis in demyelinating disease of central nervous system, paraplegia, pressure ulcer of right buttock stage four (severe form of skin damage involving full-thickness tissue loss exposing muscle, tendon, or bone), and major depressive disorder. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #67 was cognitively intact. Resident #67 had a stage four pressure ulcer not present on admission. Review of weekly skin observations revealed Resident #67 had weekly assessments completed from 06/07/25…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-11 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure pre and post dialysis communication forms. This affected one (#55) resident of one resident reviewed for dialysis. The facility census was 67.Review of medical record for Resident #55 revealed an admission date of 06/20/25 with diagnoses including but not limited to type two diabetes, end stage renal disease, and dependence on renal dialysis.Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 was cognitively intact.Review of current physician orders revealed an order to complete the pre dialysis communication form every night shift on Tuesday, Thursday, and Sunday and to complete the post dialysis form every Monday, Wednesday, and Friday.Review of pre dialysis communication forms revealed the following dates were not completed 07/07/25, 07/09/25, 07/11/25, 07/16/25,07/21/25, 07/28/25, 08/06/25, 08/11/25, 08/18/25, 08/20/25, 08/29/25, and 09/05/25.Review of post dialysis communication forms revealed the following dates…
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 · D2025-09-11 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility policy review the facility failed to ensure gloves and/or hand hygiene was completed prior to administering an insulin injection. This affected one resident #39 of one resident observed for insulin administration. Further more, the facility failed to provide sanitary environment when passing meal trays in resident's rooms. This affected two residents (#41 and #43) out of seven room trays observed. Census was 67. 1.Review of medical record for Resident #39 revealed an admission date of 08/26/22 with diagnoses including type two diabetes, dementia, and major depressive disorder. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had moderate cognitive impairment. Review of current physician orders revealed an order initiated on 09/08/25 following the observation in the dining room indicating may give medications, check blood sugar and give insulin in public spaces and dining room. Observation on 09/08/25 at 11:22 A.M. of Registered Nurse (RN…
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 before2025-02-20 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the facility policy, staff interview, and resident interview, the facility failed to ensure all care was provided to residents with pressure ulcers per thier physician's orders. This affected one (Resident #2) out of four residents reviewed for pressure ulcer care. The current census is 67. Findings include: Record review for Resident #2 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #2 include neuromyelitis, neurogenic bladder, chronic pain, and osteomyelitis. Review of Resident #2's Minimum Data Set (MDS) assessment dated [DATE] revealed upon admission the resident had one unhealed stage 3 pressure ulcer and one unhealed stage 4 pressure ulcer. Review of Resident #2's MDS assessment dated [DATE] revealed the resident had intact cognition and two unhealed pressure ulcers. Review of Resident #2's care plans dated 12/20/24 revealed the resident was at risk for pressure ulcers due to mobility. Interventions included treatment per order,…
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 · D2024-09-09 · 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 medical record review, review of the facilities Self-Reported Incident (SRI) including investigation, observations, staff interview, and review of the facilities abuse policy, the facility failed to ensure a resident was free from physical abuse. This affected one (#200) of four residents reviewed for abuse. The facility census was 66. Findings include: Review of the medical record for Resident #200 revealed an admission date of 05/06/24. Diagnoses included Alzheimer's disease with late onset, dementia with psychotic disturbance, major depression, anxiety, mild neurocognitive disorder, psychosis, and primary insomnia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #200's cognition was impaired. Resident #200 required substantial/maximal assistance from staff with eating and shower/bathe and dependent on staff for toileting, upper and lower body dressing, and personal hygiene. Review of the revised care plan dated 08/06/24 revealed Resident #200 was at risk for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-09-09 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, staff interviews, and review of the facility policy, the facility failed to ensure a resident's plan of care was revised when changes were made for the resident's comfort and positioning. This affected one (#200) of four residents reviewed for plan of care. The facility census was 66. Findings include: Review of the medical record for Resident #200 revealed admission date of 05/06/24. Diagnoses included Alzheimer's disease with late onset, dementia with psychotic disturbance, major depression, anxiety, mild neurocognitive disorder, psychosis, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #200 had cognition impairment. Resident #200 was dependent on staff for upper and lower body dressing and personal hygiene. Review of Resident #200's comprehensive plan of care dated 05/06/24 revealed it was silent for the utilization of a custom wheelchair/ tilt and space wheelchair. Review of Resident #200's 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.
- Potential for harm · D2024-09-09 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview, and facility policy review the facility failed to ensure medications were administered according to physician orders, resulting in a medication error rate exceeding five percent (%). 32 opportunities were observed with two medication errors, resulting in 6.3% error rate. This affected one (Resident #450) of four residents observed during the medication administration. The facility census was 66. Findings include: Review of the medical record for Resident #450 revealed an admission date of 09/04/02. Diagnoses included constipation. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #450 had severe cognitive impairment. Review of the physician orders dated September 2024 revealed Resident #450 was to receive Senna concentrate 8.6 milligrams (mg) give two tablets orally two times a day for constipation. The physician orders dated September 2024 were silent for physician orders for two bisacodyl (treats constipation) five mg…
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 5 citations
- Potential for harm · D2024-09-09 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility policy review and resident and staff interviews, the facility failed to ensure medications were administered to the residents without any significant medication errors. This affected two (#100 and #125) of six residents reviewed for medication administration. The facility census was 66. Findings include: 1. Review of the medical record for Resident #100 revealed an admission date of 10/11/15. Diagnoses included vascular dementia, protein calorie malnutrition, and gastrointestinal hemorrhage. Resident #100 did not have a diagnosis of diabetes mellitus. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #100 had cognitive impairment. Review of Resident #100's physician's orders revealed they were silent for physician orders for Lantus insulin, melatonin (sleep aide), Pepcid (treats heartburn), Risperdal (antipsychotic) or trazodone (antidepressant and sedative). Resident #100's medical record did not have any documentation of a medication error 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 · D2024-05-30 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and policy review, the facility failed to ensure a resident representative was notified of a resident elopement timely. This affected one (#46) resident out of the three residents reviewed for notification of changes. The facility census was 73. Findings include: Review of the medical record for the Resident #46 revealed an admission date of 04/14/22 with medical diagnoses of cerebral infarction, dementia, chronic obstructive pulmonary disease, diabetes mellitus, and Depression. Review of the medical record for Resident #46 revealed a quarterly Minimum Data Set (MDS) assessment, dated 04/03/24, which indicated Resident #46 had moderate cognitive impairment and required supervision to partial/moderate staff assistance for wheelchair mobility, was dependent for toilet hygiene and bathing, and required substantial staff assistance for transfers and bed mobility. The MDS indicated Resident #46 had a wander/elopement alarm in place daily. The MDS did not indicate…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of a facility self-reported incident (SRI), staff interviews and policy review, the facility failed to provide adequate interventions and/or supervision to ensure a resident who was assessed as being at risk for elopements did not elope from the facility. This affected one (#46) resident out of three residents reviewed for elopement. The facility census was 73. Finding include: Review of the medical record for the Resident #46 revealed an admission date of 04/14/22 with medical diagnoses of cerebral infarction, dementia, chronic obstructive pulmonary disease, diabetes mellitus, and Depression. Review of the medical record for Resident #46 revealed a quarterly Minimum Data Set (MDS) assessment, dated 04/03/24, which indicated Resident #46 had moderate cognitive impairment and required supervision to partial/moderate staff assistance for wheelchair mobility, was dependent for toilet hygiene and bathing, and required substantial staff assistance for transfers and bed mobility.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-13 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, review of a facility investigation, and review of a self-reported incident, the facility failed to ensure care plans were developed and implemented for residents with wandering and eloping behaviors. This affected two (#53 and #20) of five residents reviewed for behaviors. The current census was 68. Findings include: 1. Review of Resident #53's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #53 include dementia, aphasia, heart failure, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident has impaired cognition and was not coded as having wandering behaviors. Review of Resident #53's care plans dated April 2023 revealed there was no focus for behaviors including elopement and wandering. Review of a self-reported incident (SRI) dated 05/15/23 revealed on 05/15/23 Resident #53 walked out of the locked dementia unit, but did not leave the building. Per…
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 · E2019-09-12 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility failed to ensure yogurt was not expired. This had the potential to affect all 70 residents who reside on Mac-o-[NAME] Hall, Buckeye Hall, Myeerah Hall, and Madriver Hall. The facility census was 84. Findings include: Observation of the refrigerator at the nurses station closest to the main dining room on 09/11/19 at 5:39 P.M. revealed eight peach yogurts with a best by date of 08/29/19, one strawberry yogurt with a best by date of 08/25/19, and one peach yogurt with a best by date of 07/09/19. Interview with Dietary Manager #101 on 09/11/19 at 5:39 P.M. verified the yogurts were expired. Review of the facility policy titled Safe Food Storage and Handling of Food Brought in by Outside Sources, dated 11/21/16, revealed food or beverage that is past the manufacturer's expiration date shall be discarded.
“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
$16,801 in federal fines across 1 penalty.
- $16,801 — penalty dated 2024-01-22
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 OTTERBEIN SENIORLIFE — 20 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.2 | -0.2 vs chain |
| Health inspection | 3 of 5 | 3.0 | ≈ chain avg |
| Staffing | 2 of 5 | 3.2 | -1.2 vs chain |
| Quality measures | 4 of 5 | 4.1 | ≈ chain avg |
The other 19 homes this chain runs (chain average 3.2★, 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| OTTERBEIN LSC, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 12/23/2024 |
| OTTERBEIN HOME | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 12/23/2023 |
| BODIN, JOHN | Individual | CORPORATE DIRECTOR | — | since 01/26/2012 |
| BURTCHIN, TONY | Individual | CORPORATE DIRECTOR | — | since 12/23/2024 |
| DYE, ALEXANDER | Individual | CORPORATE DIRECTOR | — | since 12/23/2024 |
| GILDOW, RICHARD | Individual | CORPORATE DIRECTOR | — | since 12/23/2024 |
| GOBLE, AMANDA | Individual | CORPORATE DIRECTOR | — | since 12/23/2024 |
| GODWIN, STEVEN | Individual | CORPORATE DIRECTOR | — | since 12/23/2024 |
| HAUSHALTER, BARBARA | Individual | CORPORATE DIRECTOR | — | since 12/23/2024 |
| JONES, VALERIE | Individual | CORPORATE DIRECTOR | — | since 12/23/2024 |
| SIMON, THOMAS | Individual | CORPORATE DIRECTOR | — | since 01/01/2017 |
| SWORDS, AMBER | Individual | CORPORATE DIRECTOR | — | since 10/22/2024 |
| GREEN, JAMES | Individual | CORPORATE OFFICER | — | since 12/23/2024 |
| MILLER, JASON | Individual | CORPORATE OFFICER | — | since 12/23/2024 |
| WILSON, JILL | Individual | CORPORATE OFFICER | — | since 12/23/2024 |
| DANIELS, NICOLE | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 07/01/2025 |
| KRATZ, CHARLES | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/23/2024 |
CMS files one row per role, so the 20 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OH
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Ohio Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 365362. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-11, 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.