Embassy Of Willard
370 E Howard St, Willard, OH 44890 · For profit - Corporation · 59 certified beds · (419) 935-0148 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0568)
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $17,655 in federal fines (most recent 2025-04-24)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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 | 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 3 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 | 8.8% | 5.3% | 15.4% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 4.8% | 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 | 0.0% | 0.4% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 21.2% | 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 | 4.3% | 3.2% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 10.9% | 6.1% | 16.1% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 39.9% | 25.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 95.2% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.8% | 3.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 23.8% | 21.4% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 6.1% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.83 | 1.73 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 2.68 | 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.
Therapy staffing: this home’s payroll records show 0.16 therapist hours per resident per day in 2025Q4 — more than 14% of the 13,714 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 20% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 14% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.8%CMS range 8.7–18.7 | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 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 next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.02 | 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 59 beds and averages 55.8 residents a day — about 95% occupied, or roughly 3 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.93 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.43 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.68 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 3.00 hrs/resident/day on weekends vs 3.22 on weekdays — 7% thinner on weekends. RN hours go from 0.50 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 39% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
27 citations, most serious first. The 11 most serious are shown; the remaining 16 are one tap away and print in full.
- Immediate jeopardy · Jcited before2025-04-24 · 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 facility bus observation, staff interviews, medical record review, review of the incident log, review of the facility internal investigation, review of facility provided photographs, review of hospital records, review of facility bus safety manual, review of facility bus wheelchair restraint user manual, review of wheelchair manual, and review of facility policy, the facility failed to ensure Resident #11, who was identified to be dependent on staff for all aspects of care, was safely secured with a seat belt and positioned properly in a wheelchair during a transport on the facility bus. This resulted in Immediate Jeopardy and the potential for serious life-threatening injuries when Resident #11 fell out of her wheelchair mid-transport and landed on the floor, sustaining a subdural hematoma and subarachnoid hemorrhage to the left side of her head, requiring admission to the intensive care unit (ICU) for monitoring. This affected one (#11) of three residents reviewed for use of assisted device during…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2026-07-16 · tag F0838 — failed to assess facility resources and resident needs — widespreadConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of the facility assessment, staff interview, and policy review, the facility failed to ensure the facility assessment evaluated residents to determine the number of staff needed in the facility. This had the potential to affect all residents. The facility census was 55. Findings include:Review of the Facility Assessment last dated 04/02/26 stated the facility determined the facility needed one full time Director of Nursing (DON), one full time Assistant Director of Nursing (ADON), nine full time licensed nurse supervisors, five as needed licensed nurse supervisors, 17 full time nursing assistants, two part time nursing assistants, and four as needed nursing assistants for nursing staff. Further review of the facility assessment revealed no evaluation was completed to determine the number of staff needed for the acuity of the residents.Interview on 07/16/26 at 9:41 A.M. with the Administrator verified the facility assessment did not evaluate resident needs to determine the number of staff needed in the facility. Furthermore, the Administrator verified the number of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-07-16 · tag F0568 — isolatedProperly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
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 interviews, review of resident fund accounts, and review of facility policy, the facility failed to appropriately manage resident funds. This affected one (#02) of one resident reviewed for personal funds. The facility census was 55.Findings include:Review of the medical record for Resident #02 revealed an admission date of 10/22/25 with diagnoses that included acute respiratory failure with hypoxia, hypertension, and type II diabetes mellitus.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #02 had a Brief Interview for Mental Status (BIMS) score of 15 that indicated the resident was alert and oriented to person, place, and time. Further review of the MDS assessment revealed Resident #02 was dependent on staff for activities of daily living (ADLs) and had a lower extremity impairment on one side. Review of the care plan dated 10/29/25 revealed Resident #02 was independent with meeting emotional, intellectual, physical and social needs, and had an ADL…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-07-16 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, staff interview, and policy review, the facility failed to ensure advance directives were consistent throughout the medical record. This affected two (#14, #40) of two residents reviewed for advance directives. The facility census was 55.Findings include: 1. Review of the medical record for Resident #14 revealed an admission date of [DATE]. Diagnoses included hypertension, atrial fibrillation, dementia, chronic kidney disease, and congestive heart failure. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. Review of a signed Do Not Resuscitate (DNR) Comfort Care (CC) form dated [DATE] and located in the resident's physical paper chart revealed the resident had a chosen a DNRCC-Arrest (DNRCC-A) protocol (the DNR Comfort Care protocol would be implemented in the event of a cardiac or respiratory arrest). Review of a physician order in the electronic medical record, dated [DATE] and discontinued on [DATE],…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-07-16 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, staff interview, and policy review, the facility failed to ensure adequate monitoring for psychotropic medication effectiveness and adverse effects/side effects. This affected three (#03, #09, and #25) of five residents reviewed for unnecessary medications. The facility identified 47 residents receiving psychotropic medications. The facility census was 55.Findings include: 1. Review of the medical record for Resident #03 revealed an admission date of 05/06/26 and a readmission date of 07/10/26. Diagnoses included depression, anxiety, chronic kidney disease, chronic obstructive pulmonary disease, and type two diabetes mellitus. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of the plan of care initiated 05/07/26 revealed the resident was at risk for episodes of anxiety. Interventions revealed to administer medications as ordered and monitor for side effects and effectiveness. Review of the plan 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 before2026-07-16 · 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 resident record review, resident interview, staff interview, and facility policy review, the facility failed to implement a dental care plan for a resident. This affected one (#35) of one resident reviewed for dental services. The facility census was 55.Findings include:Review of the medical record for Resident #35 revealed she was admitted to the facility on [DATE] with diagnoses that included volvulus, intestinal obstruction, and epilepsy.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 had a Brief Interview for Mental Status (BIMS) score of 12 that indicated she was alert and oriented to person, place, and time. Review of the MDS assessment revealed Resident #35 required some assistance from staff for activities of daily living (ADLs).Review of the care plan dated 05/02/26 revealed Resident #35 required assistance with ADLs, was at risk for weight loss, chewing problems, and had oral and/or dental health problems with interventions that included refer to dental…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-07-16 · 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 observation, review of the medical record, interview, and policy review, the facility failed to ensure wound treatments were administered per physician orders. This affected two (#14, #10) of two residents reviewed for pressure ulcers. The facility identified seven residents with pressure ulcers. The facility census was 55. Findings include: 1. Review of the medical record for Resident #14 revealed an admission date of 05/29/26. Diagnoses included hypertension, atrial fibrillation, dementia, chronic kidney disease, and congestive heart failure. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. The resident had a stage three pressure ulcer present on admission. The resident was dependent on staff for toileting and transfers. The resident required substantial/maximal assistance for bed mobility. Review of the care plan initiated 05/29/26 revealed the resident was admitted to the facility with a stage three pressure ulcer to the sacrum.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-07-16 · 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, medical record review, staff interview, review of the manufacturer's instructions for the mechanical lift slings, and policy review, the facility failed to ensure monitoring was in place for mechanical lift slings utilized in the facility. This affected two (#01 and #34) of two residents reviewed for mechanical lift slings. The facility identified 12 residents requiring the use of slings for mechanical lift transfers. The facility census was 55.Findings include:1. Review of Resident #01's medical record revealed an admission date of 01/09/25. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, type two diabetes mellitus, aphasia, muscle weakness, and hypertension.Review of Resident #01's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #01 had severely impaired cognitive skills for daily decision making. Furthermore, Resident #01 was dependent for chair to bed and bed to chair transfers.Review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-07-16 · 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, medical record review, staff interview, and policy review, the facility failed to ensure oxygen orders specified liters per minute (lpm). This affected one (#10) of three residents reviewed for respiratory care. The facility census was 55.Findings include:Review of Resident #10's medical record revealed an admission date of 12/30/25. Diagnoses included bipolar disorder with psychotic features. chronic obstructive pulmonary disease (COPD), hypertension, anxiety, muscle weakness, pressure ulcer of the sacral region, hypertensive chronic kidney disease, mild persistent asthma, age-related osteoporosis, and urinary incontinence. Review of Resident #10's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of 11. Furthermore, Resident #10 required the use of oxygen therapy. Review of Resident #10's care plan dated 06/24/26 revealed Resident #10 had altered respiratory status or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-07-16 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for each 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 resident record review, resident interview, staff interview, and facility policy review, the facility failed to ensure timely dental services. This affected one (#35) of one resident reviewed for dental services. The facility census was 55. Findings include:Review of the medical record for Resident #35 revealed she was admitted to the facility on [DATE] with diagnoses that included volvulus, intestinal obstruction, and epilepsy.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 had a Brief Interview for Mental Status (BIMS) score of 12 that indicated she was alert and oriented to person, place, and time. Review of the MDS assessment revealed Resident #35 required some assistance from staff for activities of daily living (ADLs).Review of the care plan dated 05/02/26 revealed Resident #35 required assistance with ADLs, was at risk for weight loss, chewing problems, and had oral and/or dental health problems with interventions that included refer to dental services, be free…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-07-16 · 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, medical record review, staff interview, and policy review, the facility failed to ensure infection control standards were maintained during wound care. Furthermore, the facility failed to implement Enhanced Barrier Precautions (EBP) when the staff failed to wear the appropriate personal protective equipment (PPE) for resident care when the resident was identified as requiring EBP. This affected three (#10, #33 and #14) of three residents reviewed for infection control practices. The facility identified 13 residents in the facility requiring EBP. The facility census was 55.Findings include: 1. Review of Resident #10's medical record revealed an admission date of 12/30/25. Diagnoses included bipolar disorder with psychotic features. chronic obstructive pulmonary disease (COPD), hypertension, anxiety, muscle weakness, pressure ulcer of the sacral region, hypertensive chronic kidney disease, mild persistent asthma, age-related osteoporosis, and urinary incontinence. Review of Resident #10's…
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 16 citations
- Potential for harm · Dcited before2026-05-28 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed medical record review, interview, and review of the facility policy, the facility failed to ensure medications were administered as physician ordered. This affected one (#54) of three residents reviewed for medication administration. The facility census was 53.Findings include:Review of the closed medical record for Resident #54 revealed an admission date of 02/27/26 and a discharge date of 05/24/26. Diagnoses included malignant neoplasm of pancreas, paranoid schizophrenia, and Type II diabetes mellitus. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had impaired cognition as evidence by a Brief Interview for Mental Status (BIMS) score of 06. This resident was assessed to require substantial assistance with activities of daily living (ADLs).Review of the hospice admission orders dated 02/27/26 revealed Resident #54 had orders for Cardizem (treats cardiovascular conditions) 120 milligrams (mg) daily, insulin glargine 100 units (u) per milliliter (ml) inject 40…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-28 · 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 closed medical record review, staff interview and review of facility policy, the facility failed to ensure residents were free from significant medication errors. This affected one (#54) of three residents reviewed for medication administration. The facility census was 53.Findings include:Review of the closed medical record for Resident #54 revealed an admission date of 02/27/26 and a discharge date of 05/24/26. Diagnoses included malignant neoplasm of pancreas, paranoid schizophrenia, and Type II diabetes mellitus. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had impaired cognition as evidence by a Brief Interview for Mental Status (BIMS) score of 06. This resident was assessed to require substantial assistance with activities of daily living (ADLs).Review of the Hospice admission notes revealed Resident #54 was admitted to Hospice on 02/27/26. Resident #54 had orders to receive insulin glargine 100 units (u) per milliliter (ml); inject 40 units into the skin two…
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 · E2024-04-25 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and staff interview, the facility failed to ensure the menu was followed for residents receiving pureed diets. This affected six residents (#3, #27, #30, #37, #45, and #50) who were prescribed a pureed diet. The facility census was 50. Findings include: Review of the lunch meal spreadsheet for 04/23/24 revealed residents on a pureed diet should include pureed dinner rolls using one #20 scoop (equivalent to 3.5 tablespoons). Observation of tray line on 04/23/24 from approximately 12:15 P.M. to 12:45 P.M. revealed the facility did not include the pureed dinner rolls and/or an appropriate substitution to residents receiving pureed food items. Interview on 04/23/24 at 12:45 P.M. with [NAME] #405 verified pureed dinner rolls were available on the tray service line but were not served to residents receiving pureed meals at the time of observation. Review of the facility's list of residents on a pureed diet revealed Residents #3, #27, #30, #37, #45, and #50 were on a pureed diet. Review of the facility policy titled Accuracy and Quality of Tray Line…
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 · D2024-04-25 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, resident and staff interviews, and review of the facility policy, the facility failed to ensure the resident's sheets were maintained in a clean condition. This affected one (Resident #39) of 50 residents reviewed for clean linens. The facility census was 50. Findings include: Review of the medical record for Resident #39 revealed an admission date of 06/17/21 with a diagnosis of psoriasis. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had intact cognition and was independent for bed mobility, lying to sitting, sitting to standing, and transferring from the bed to the chair. Review of the current physician orders for April 2024 revealed Resident #39 was scheduled for showers on Fridays and Tuesdays. Interview and observation on 04/22/24 at 12:08 P.M. with Resident #39 revealed his sheets were stained along the edge of the mattress near the head of his bed, and his pillow case had several spots that appeared to be…
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 · D2024-04-25 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and review of the facility incontinence policy, the facility failed to ensure timely incontinence care was provided to a resident who was incontinent and dependent on staff for toileting This affected one (Resident #30) of two residents reviewed for incontinence care. The facility census was 50. Findings include: Review of the medical record revealed Resident #30 admitted to the facility on [DATE]. Diagnoses included metabolic encephalopathy, mood disorder, seizure disorder, chronic obstructive pulmonary disease, dementia, anxiety disorder, and major depression. Review of the Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #30 had severely impaired cognition, dependent on staff for the completion of activities of daily living, always incontinent of bowel and bladder, and at risk for pressure ulcer development. Review of the nursing plans of care dated 01/09/24 revealed Resident #30's plan addressed an actual area of skin impairment…
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 before2024-04-25 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure medications were administered and were not left at the resident bedside. This affected one (#40) of one resident reviewed for pharmaceutical services. The facility census was 50. Findings include: Review of Resident #40's medical record revealed an admission date of 11/05/21. Diagnoses included chronic gout, type II diabetes mellitus, malignant melanoma of skin, hypokalemia, hydronephrosis, hypertension, hyperlipidemia, lymphedema, muscle weakness, and supraventricular tachycardia. Observation on 04/22/24 at 10:21 A.M. revealed Resident #40 had a medication cup containing eight unidentified pills located on a table in the resident's room. During an interview on 04/22/24 at 10:25 A.M., Resident #40 reported the medications were their morning medications. Resident #40 reported staff were not supposed to leave medications in the room but they always did because they trusted Resident #40 and because Resident #40 took approximately 15 minutes to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-25 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interview, and review of the facility policy, the facility failed to ensure staff used appropriate hand hygiene during meal services. This affected three (#17, #21, and #22) of four residents observed during meal service on the 400-hall. The facility census was 50. Findings include: Observation on 04/22/24 at 7:57 A.M. revealed State Tested Nurse Aide (STNA) #301 passing breakfast trays to residents eating in their rooms. STNA #301 entered Resident #13's room and provided her breakfast tray and removed the lids from the food items. Resident #13 requested some assistance and STNA #310 adjusted the socks on Resident #13's feet. STNA #301 exited Resident #13's room, did not perform hand hygiene, and picked up the tray for Resident #22. STNA entered Resident #22's room, picked up her computer tablet and placed the breakfast tray on the overbed table. STNA #301 then removed the lids from Resident #22's meal items and exited her room without performing hand hygiene. Interview on 04/22/24 at 8:00 A.M. with STNA #301 confirmed she touched Resident #13's socks…
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 before2024-04-25 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, staff interviews, review of the facility policy and review of staff in-service, the facility failed to ensure staff wore personal protective equipment (PPE) when providing care to residents in enhanced barrier precautions (EBP). This affected one resident (#26) of two residents observed in EBP. The facility census was 50. Findings include: Review of the medical record for Resident #26 revealed an admission date of 03/12/24 with a diagnosis of acquired absence of right toe. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 had intact cognition and required limited assistance of one person for transfers. Review of the current physician order dated 04/05/24 revealed Resident #26 was in EBP precautions for a chronic wound. The order stated gloves and gown should be worn when transferring the resident. Review of the current care plan for Resident #26 revealed he had an area of skin impairment related to a right foot stump wound.…
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 · D2023-11-06 · 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 observation, record review, and facility staff interview the facility failed to provide wound care as ordered for one (#30) of three residents reviewed for wound care. The facility census was 52. Findings Include: Review of Resident #30's medical record revealed the resident was admitted on [DATE], diagnoses included basal cell carcinoma of face, heart disease, type two diabetes, history of falls and myocardial infarction. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #30, revealed the resident was cognitively intact, had no behaviors and required extensive assistance with dressing and toileting. Review of the active physician orders for Resident #30, revealed the resident had a daily wound care order for her basal cell carcinoma wound to her chin that stated to wash hands prior to changing the dressing, cleanse the wound once daily gently with soap and water or normal saline, pat dry, do not rub the wound, apply Aquaphor (healing ointment), Cerave (healing…
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 before2021-11-12 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, observation, resident and staff interview, review of the Centers for Disease Control and Prevention's guidance, and review of the facility's policy, the facility failed to ensure newly admitted residents, who were unvaccinated for COVID-19, were placed on transmission-based precautions and staff wore appropriate personal protective equipment (PPE) to potentially limit the spread of COVID-19. This had the potential to affect 12 residents who were unvaccinated and residing in the facility. Findings include: Review of the medical record for Resident #134 revealed an admission date of 11/01/21 and a readmission date of 11/05/21. Diagnoses included acute cystitis with hematuria and urinary tract infection (UTI). Review of the Medicare five-day Minimum Data Set (MDS) assessment, dated 11/02/21, revealed Resident #134 was cognitively intact. Review of the physician orders for November 2021 revealed no orders related to transmission-based precautions. Observation on 11/07/21 at 10:13 A.M. of Resident #134's room revealed a sign on the door stating Resident…
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 before2021-11-12 · 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 medical record review, observation, staff interview, and review of the facility's policy, the facility failed to ensure comprehensive care plans were developed and the facility failed to implement fall interventions in the resident's care plan. This affected three (#2, #14 and #25) of 16 residents reviewed for care plans. The facility census was 37. Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 06/28/19 and a readmission date of 11/07/21. Diagnoses included infection pressure ulcer of sacral (bony area at the base of the spine) region, cellulitis (bacterial skin infection) of left lower limb, end stage renal disease, type II diabetes mellitus, hypotension, and morbid (severe) obesity due to excess calories. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/16/21, revealed Resident #2 was cognitively intact and had one stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present…
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 · D2021-11-12 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, resident and staff interview, and review of the facility's policy, the facility failed to ensure residents received vision services. This affected one (#4) of one resident reviewed for vision services. The facility census was 37. Findings include: Review of the medical record for Resident #4 revealed an admission date of 05/14/21 and a readmission date of 09/14/21. Diagnoses included type II diabetes mellitus with diabetic polyneuropathy. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/14/21, revealed Resident #4 was cognitively intact and did not wear corrective lenses. Interview on 11/07/21 at 9:49 A.M. with Resident #4 revealed he was unaware if vision services were available at the facility. Resident #4 stated he wore eyeglasses but had not had any since his admission because he had broken them and was not able to get out to see his eye doctor. Interview on 11/09/21 at 12:11 P.M. with Social Services Director (SSD) #246 verified Resident #4 had not been seen by the eye doctor since his admission to the facility. SSD #246 stated…
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 before2021-11-12 · 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
Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure the resident's fall interventions were implemented to reduce the risk of injury. This affected one (#5) of one resident reviewed for falls. The facility census was 37. Findings include: Review of the medical record for Resident #5 revealed an admission date of 07/09/21. Diagnoses included type II diabetes mellitus with diabetic chronic kidney disease, cerebral infarction (stroke) without residual deficits, altered mental status, chronic kidney disease, stage III, vascular dementia without behavioral disturbance, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/14/21, revealed Resident #5 was severely cognitively impaired and required extensive two person assist with bed mobility, transfers, dressing, toilet use, and personal hygiene. In addition, Resident #5 had two or more falls since admission. Review of the plan of care, initiated 07/20/21, revealed Resident #5 was at risk for falls and potential injury.…
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 before2021-11-12 · 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
Based on medical record review, observation, staff interview, and review of the facility's policy, the facility failed to ensure a physician order was obtained for oxygen administration and failed to date oxygen tubing per physician order. This affected one (#25) of one resident reviewed for oxygen administration. The facility identified eight residents receiving oxygen therapy. The facility census was 37. Findings include: Review of the medical record for Resident #25 revealed an admission date of 08/11/21. Diagnoses included anxiety disorder and chronic obstructive pulmonary disease (COPD). Review of the admission Minimum Data Set (MDS) assessment, dated 08/24/21, revealed Resident #25 was moderately cognitively impaired and received oxygen therapy. Review of the physician's orders for Resident #25, dated 08/18/21, revealed an order to change and date oxygen tubing every Wednesday on night shift. There was no order for oxygen administration. Observation on 11/07/21 at 10:10 A.M. of Resident #25's oxygen tubing revealed the tubing was not labeled with the date it was changed.…
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 · D2021-11-12 · tag F0744 — failed to care for residents with dementia — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, staff interview, and review of the facility's policy, the facility failed to ensure a resident with dementia was adequately assessed and an individualized plan of care was developed to meet the resident's needs. This affected one (Resident #5) of three residents reviewed for dementia care. The facility census was 37. Findings include: Review of the medical record for Resident #5 revealed an admission date of 07/09/21. Diagnoses included altered mental status and vascular dementia without behavioral disturbance. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/14/21, revealed Resident #5 was severely cognitively impaired and had a diagnosis of non-Alzheimer's dementia. Review of the plan of care initiated on 07/20/21 revealed no goals or interventions related to dementia care were identified for Resident #5. Interview on 11/09/21 at 10:14 A.M. with the Director of Nursing (DON) revealed Resident #5 had significant behavior concerns upon admission and was admitted to the facility after another facility refused to accept him back due…
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 · D2021-11-12 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, resident and staff interview, and review of the facility's policy, the facility failed to ensure resident rooms were maintained in good repair and resident room equipment was in operable condition. This affected two residents (#4 and #25) of two residents reviewed for physical environment. The facility census was 37. Findings include: 1. Observation on 11/07/21 at 9:35 A.M. of Resident #4's room revealed the corner of the wall near the sink and the bathroom door was damaged, exposing cracked and crumbling drywall and the baseboard was broken and pulled away from the wall. On the wall to the right of the bathroom door was an area, approximately two inches above the baseboard, approximately seven inches in length of exposed drywall. Observation of an area to the right of the window revealed seven smaller areas of exposed drywall. In addition, the left closet door handle was broken in half, exposing sharp metal edges. Interview with Resident #4 at the time of the observation revealed the walls had been damaged for some time. Resident #4 stated he believed the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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
$17,655 in federal fines across 1 penalty.
- $17,655 — penalty dated 2025-04-24
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 EMBASSY HEALTHCARE — 33 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 | 2 of 5 | 2.4 | -0.4 vs chain |
| Health inspection | 2 of 5 | 2.0 | ≈ chain avg |
| Staffing | 2 of 5 | 1.8 | +0.2 vs chain |
| Quality measures | 4 of 5 | 4.4 | -0.4 vs chain |
The other 32 homes this chain runs (chain average 2.4★, 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 | Since |
|---|---|---|---|
| SNOOK, MOLLIE | Individual | W-2 MANAGING EMPLOYEE | since 01/01/2024 |
| CICCONE, NICHOLAS | Individual | CORPORATE OFFICER | since 01/01/2024 |
| HANDLER, AARON | Individual | CORPORATE OFFICER | since 01/01/2024 |
| REPCHICK, GEORGE | Individual | CORPORATE OFFICER | since 01/01/2024 |
The source lists no ownership percentage for any party here — 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.
About 79% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $322K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OH
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Ohio Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-09-01 — CMS provider number 365343. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-07-16, 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 →
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