Wilmington Nursing & Rehab
75 Hale Street, Wilmington, OH 45177 · For profit - Limited Liability company · 76 certified beds · (937) 382-1621 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has citations for mishandling residents’ money or property (F0568, F0569)
- a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (2/5)
- about 19% of its spending goes to commonly-owned related companies
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
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 | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 4 to 5 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 | 6.7% | 5.3% | 15.4% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 13.1% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.2% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.5% | 0.4% | 2.0% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 19.7% | 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 | 3.4% | 3.2% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 4.9% | 6.1% | 16.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 29.0% | 25.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 96.4% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.1% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 19.6% | 21.4% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 8.6% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.9% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 66.1% | 75.6% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 20.3% | 24.9% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 28.4% | 12.9% | 12.0% | 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.
34.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 26 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.18 therapist hours per resident per day in 2026Q1 — more than 18% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 15% 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 | 34.0%CMS range 23.2–50.0 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.3%CMS range 7.7–16.0 | 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 — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 | 0.76 | 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 76 beds and averages 61.2 residents a day — about 81% occupied, or roughly 15 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.24 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.63 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.91 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 3.03 hrs/resident/day on weekends vs 3.32 on weekdays — 9% thinner on weekends. RN hours go from 0.73 to 0.38 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 41% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
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 fewer than at the previous inspection — improving. 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.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
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.
25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.
- Potential for harm · E2026-06-11 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, interview, and facility policy, the facility failed to ensure medications were administered with a medication error rate less then 5%. This affected three (#28, #41, and #62) residents observed during medication administration. A total of 29 medication opportunities with three errors were observed for total error rate of 10%. The facility census was 63. Findings include: 1.Review of the medical records for Resident #28 revealed an admission date of 01/03/25. Diagnoses included dementia, peripheral vascular disease, and Alzheimer's disease. Review of physician orders dated 02/18/26 revealed Resident #28 had an order memantine 5 milligrams (mg) two tablets twice a day. Observation on 06/10/26 from 7:20 A.M. through 7:26 A.M. with Registered Nurse (RN) #274 revealed she administered medications to Resident #28. Medications administered included aspirin 81 mg one tablet, furosemide 20 mg one tablet, memantine 10 mg two tablets, and tamsulosin hydrochloride (HCL) 0.4 micrograms (mcg) one tablet. Interview on 06/10/26 at 10:10 A.M. RN #274 verified she…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-11 · 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, record review, interview and review of facilty policy, the facility failed to provide proper incontinence care to one (#48) out of one residents reviewed for incontinence care. The facility census was 63.Findings include: Record review for Resident #48 revealed this resident was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, muscle weakness, and radiculopathy lumbar region. Review of the MDS assessment dated [DATE] revealed the resident had severely impaired cognition. This resident was assessed to require to be dependent on staff for all activities of daily living (ADLs). Resident is assessed to always be incontinent of bowel and bladder.Observation on 06/10/26 at 9:23 A.M revealed CNA #260 put on a gown and applied gloves. She then put clean washcloths in Resident #48's sink and turned the water on. CNA #260 sat the washcloths on the bedside table on top of a new garbage bag. CNA #260 removed Resident #48's covers and clothes with the same gloves and started…
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 · D2026-06-11 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews, record review, and policy review, the facility failed to provide timely pain management for one (#85) out of three residents reviewed for pain management. The facility census was 63. Findings include:Review of medical records for Resident #85 revealed an admission date of 06/08/26 at 11:30 P.M. Diagnoses included complete traumatic amputation hip and knee, peripheral vascular disease, type two diabetes, and abdominal hernia without obstruction or gangrene. Review of the physician orders dated 06/09/26 revealed Resident #85 had an order for Tylenol 325 milligram (mg) two tablets every six hours routine. Times to be administered were 12:00 A.M., 6:00 A.M., 12:00 P.M., and 6:00 P.M. Also, Resident #85 had an order for oxycodone/acetaminophen 10-325 mg take one tablet as needed every six hours. Review of the medication administration record dated 06/09/26 revealed that Resident #85 had not been administered Tylenol 325 mg two tablets at 12:00 P.M. Review of Resident #85's vital sign form revealed on 06/09/26 at 2:16 P.M. the resident's pain was assessed…
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 before2026-06-11 · 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
Based on observation, interview, record review, and facility policy, the facility failed to be free from significant medication errors for one (#62) resident observed for medication administration. The facility failed to administer medications per physician order for one (#85) out of three residents reviewed for pain management. The facility census was 63. Findings include: 1. Review of medical records for Resident #85 revealed an admission date of 06/08/26 at 11:30 P.M. Diagnoses included complete traumatic amputation hip and knee, peripheral vascular disease, type two diabetes, and abdominal hernia without obstruction or gangrene. Review of the physician orders dated 06/09/26 revealed Resident #85 had an order for Tylenol 325 milligram (mg) two tablets every six hours routine. Times to be administered were 12:00 A.M., 6:00 A.M., 12:00 P.M., and 6:00 P.M. Review of the medication administration record dated 06/09/26 revealed that Resident #85 had not been administered Tylenol 325 mg two tablets at 12:00 P.M.Interview on 06/09/26 at 2:20 P.M. Resident #85 stated she had alot of pain…
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 before2024-12-26 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, resident interview, and policy review, the facility failed to ensure food was served warm and palatable. This had the potential to affect all but one Resident (#32) who received food from the facility's kitchen. The facility census was 58. Findings include: Review of the lunch menu for 12/26/24 revealed the residents received a choice of fish patty or chicken fingers, broccoli casserole, dinner roll and Jello for dessert. Observation of meal line service on 12/26/24 from 11:00 A.M. to 12:30 P.M., revealed the lunch meal consisted of a choice of a fish patty or chicken fingers, broccoli casserole and Jello for dessert. Cooking temperatures obtained at this time by using a facility thermometer revealed the fish patty was at 180 degrees Fahrenheit, chicken fingers at 190 degrees Fahrenheit and broccoli casserole at 182 degrees Fahrenheit. Steam table holding temperatures obtained by using a facility thermometer, at the time of plating, revealed the fish patty was at 202 degrees Fahrenheit, chicken fingers at 205 degrees Fahrenheit and broccoli…
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 · E2024-07-11 · 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 and staff interviews, and policy review, the facility failed to complete quarterly care conferences for residents residing in the facility. This affected four (#18, #21, #29, and #52) of five residents reviewed for care conferences. The facility census was 63. Findings include: 1. Review of the medical record for Resident #18 revealed an admission date of 09/04/19. Diagnoses included type two diabetes mellitus, chronic obstructive pulmonary disease (COPD), convulsions, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 had moderate cognitive impairment. Review of the medical record for care conferences for the last 12 months revealed Resident #18 only had two care conferences dated 09/27/24 and 04/10/24. Interview on 07/09/24 at 2:40 P.M. with Social Services Designee (SSD) #145 verified Resident #18 had only received two care conferences in the last 12 months. 2. Review of the medical record for Resident #21…
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 · D2024-07-11 · tag F0687 — failed to care for feet properly — isolatedProvide appropriate foot care.
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, resident and staff interviews, observation, and policy review, the facility failed to ensure residents received timely foot care. This affected one (#18) of three residents reviewed to activities of daily living. The facility census was 63. Findings include: Review of the medical record for Resident #18 revealed an admission date of 09/04/19. Diagnoses included type two diabetes mellitus (DM II), chronic obstructive pulmonary disease (COPD), convulsions, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 had moderate cognitive impairment. Resident #18 was dependent on staff with bathing. Review of the podiatry note dated 10/27/23 revealed Resident #18 was seen and needed to follow up in two to three months. The podiatry note dated 01/12/24 revealed Resident #18 refused to be seen. The podiatry appointment dated 03/29/24 revealed Resident #18 was supposed to be seen but the podiatrist canceled. The podiatry…
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 before2024-07-11 · 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, staff interview, and policy review, the facility failed to ensure residents were free from significant medication errors. This affected one (#39) of one resident reviewed for significant medication errors. The facility census was 63. Findings include: Review of the medical record for Resident #39 revealed an admission date of 12/01/23. Diagnoses included acute embolism and thrombosis of deep veins of lower extremity and atherosclerotic heart disease of native coronary artery without angina pectoris. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had severely impaired cognition. Review of Resident #39's progress note dated 01/30/24 revealed an order was received to increase Warfarin (blood thinner) to six milligrams (mg) on Monday and Thursday, and continue five mg on Saturday, Sunday, Tuesday, Wednesday, and Friday. Review of Resident #39's physician orders revealed an order dated 01/30/24 to 02/15/24 for Warfarin five mg once a day with…
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 · F2023-11-08 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 store, prepare, distribute, and serve food under sanitary conditions. This had the potential to affect all 65 residents residing in the facility. Findings include: 1. Observation of the kitchen on 11/07/23 from 9:00 A.M. to 9:41 A.M. with Dietary Manager #100 revealed the following concerns: Observation of the four tray line warmers revealed the water under each bin the water was milk- like in color withfloating white particles. One of the bins had dried food on the sides of the bin. Observation of the shelves directly underneath the serving area revealed there food particles, a dirty scoop, a bottle of syrup, crumbled aluminum file and a plastic bin containing non-kitchen items. Observation of the plate warmer on the left side revealed the outside of the warmer was dirty with food particles, fingerprints, and an identified dry white substance near the top of the warmer. Observation of the outside of the microwave oven revealed the handle was covered with a dry crusty like substance, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-08 · tag F0804 — failed to serve food at safe, palatable temperature — isolatedEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation, staff interview, and review of the facility policy the facility failed to ensure residents received a mechanical soft textured diet as ordered. This affected three (Residents #14, #30, and #32) of three residents with orders for a mechanical soft diet. The facility census was 65. Findings include: Review of the facility menu for the lunch meal on 11/08/23 revealed the lunch entrée for that date was a turkey and cheese sandwich. Review of the dietary spreadsheet signed by the facility dietitian for the lunch entrée on 11/08/23 revealed residents with physician order for a mechanical soft diet should receive a scoop of ground turkey and two slices of bread. Observation of the lunch service line on 11/08/23 from 11:15 A. M. to 12:20 P. M. revealed the staff prepared a scoop of ground turkey as the entrée from Residents #14, #30, and #32, facility-identified residents with orders for mechanical soft diet. Residents #14, #30, and #32 did not receive bread with the meal as specified per the dietary spreadsheet. Interviews on 11/08/23 at 12:20 P.M. with…
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 15 citations
- Potential for harm · Dcited before2023-09-21 · 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 record review, observations, staff interviews and policy review, the facility failed to ensure fall interventions were in place for a resident who was at risk for falls. This affected one (#20) of three reviewed for falls. Facility census was 62. Findings include: Review of medical record for Resident #20 revealed admission date of 06/19/23. Diagnoses include Cerebral Palsy, epilepsy and incontinence. A care plan initiated 06/20/23 revealed Resident #20 was a fall risk and interventions included Dycem (nonslip material) to wheelchair. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #20 had severe cognitive impairment. Resident #20 required extensive one person assistance for bed mobility, transfers, eating and toileting. Observation on 09/20/23 at 11:16 A.M. revealed Resident #20 had requested to go to the bathroom and was seated in a wheelchair. Further observations of Resident #20's wheelchair revealed there was no Dycem present. State Tested Nursing Assistant (STNA) #33 also…
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 before2023-09-21 · 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, resident, Physician and Nurse Practitioner interviews, review of information from the Centers for Disease Control and Prevention (CDC) and policy review, the facility failed to implement their policy regarding reporting infectious diseases as required. This affected two (#13 and #14) of three resident reviewed for infections. Facility census was 62. Findings include: 1. Review of medical record for Resident #14 revealed admission date of 01/09/18. Diagnoses include diabetes mellitus type 1, stage 4 kidney disease, depression and dementia. The resident remains in the facility. The quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 10 indicating Resident #14 had impaired cognition. She required extensive two-person assistance for toileting, one person assistance for bed mobility, total dependence for transfer and supervision for eating. Record review of the 08/11/23 Dermatology office note for Resident #14 revealed no…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2022-03-15 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interview, policy review, review of information from the Centers for Disease Control and Prevention (CDC) and review of information from the Centers for Medicare and Medicaid Services (CMS), the facility failed to properly don (put on) personal protective equipment (PPE) and/or wash their hands to potentially prevent the spread of Coronavirus Disease 2019 (COVID-2019). This had the potential to affect all 62 residents residing in the facility. The facility census was 62. Finding include: 1. Observation on 03/08/22 at 2:44 P.M. of the facilities laundry room revealed housekeeper manager (HM) #114 and housekeeper (HK) #116 folding laundry with no mask or eye protection. Interview with HM #114 on 03/08/22 at 2:44 P.M. revealed she decided not to wear a mask or eye protection because she is in laundry today and the room is hot. HM #114 confirmed she has never receiving training to work in laundry and does not know how she would handle potentially infectious laundry. HM #114 stated she is guessing she would put on gloves. Interview with HK #116 on 03/08/22 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-03-15 · 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 and Nurse Practitioner (NP) interview and policy review, the facility failed to notify the facility physician of a change of condition for Resident #215. This affected one (#215) out of three resident reviewed for notification of change. The facility census was 62. Findings Include: Review of the medical record for the Resident #215 revealed an admission date of 11/16/21 and he was discharged to the hospital on [DATE]. His diagnoses included obesity, disorder of kidney and ureter, anemia, disease of the spinal cord, diabetes mellitus 2, essential primary hypertension, osteoarthritis, and spinal stenosis. Review of the admission Minimum Data Set (MDS) assessment, dated 11/23/21, revealed the Resident #215 had intact cognition as evidenced by a score of 14 on his brief interview for mental status (BIMS) examination. Resident #215 required extensive assistance from staff with bed mobility and eating. Further review of the MDS assessment revealed Resident #215 was totally…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-03-15 · 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, observations and staff interview, the facility failed to develop a plan of care for the use of psychotropic medications for Resident #3 and #309. This affected two (#3 and #309) of eight residents reviewed for unnecessary medications. Additionally, the facility failed to ensure Resident #41's care plan accurate reflected the resident hemodialysis access site. This affected one (#309) of one resident reviewed for dialysis. The facility census is 62. Findings included: 1. Medical record review for Resident #3 revealed that she was admitted to the facility on [DATE]. Diagnoses include dementia with behavior disturbance, anxiety disorder, cerebral infarction, diabetes mellitus, and major depression. Review of the physician orders for Resident #3 revealed she was prescribed Buspirone five milligrams (mg) by mouth three times daily for anxiety on 06/01/21. On 06/02/21, Resident #3 was prescribed citalopram 10 mg by mouth once daily. On 02/16/22, the Buspirone was decreased to five mg by…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-03-15 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of Medscape medication guidance, the facility failed to ensure a resident was free of unnecessary psychotropic medications when the facility failed to have adequate indication of use for a resident's psychotropic medications, failed to provide monitoring for the use of psychotropic medications and failed to monitor for side effects of psychotropic medications. This affected one resident (#47) of seven resident's reviewed for unnecessary medications. The facility census was 62. Findings included: Review of Resident #47's medical record revealed an admission date of 12/27/21. Diagnoses included chronic obstructive pulmonary disease with acute exacerbation, chronic bronchitis, protein-calorie malnutrition, diabetes, asthma, hypertension, developmental disorder of speech and language, atherosclerotic heart disease, paranoid schizophrenia, unspecified psychosis, and dysphagia. Review of Resident #47's Minimum Data Set (MDS) dated [DATE] revealed the Brief…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-03-15 · tag F0770 — failed to provide lab services — isolatedProvide timely, quality laboratory services/tests to meet the needs of residents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and policy review, the facility failed to obtain laboratory services as ordered by a physician. This affected two (#54, #215) out of two residents reviewed for laboratory services. The facility census was 62. Findings include: 1. Record review for Resident #54 revealed an admission date of 02/01/21. Diagnosis included paraplegia, schizoaffective disorder, abscess of epididymis, cutaneous abscess of the perineum, major depressive disorder, mood disorder, anemia, gastro esophageal reflux disease, insomnia, and diabetes mellitus 2. Review of the minimum data set (MDS) annual assessment, dated 02/08/22, revealed Resident #54 has intact cognition as evidenced by his brief interview for mental status (BIMS) score of 14. Further review of the MDS assessment revealed Resident #54 required extensive assistance from staff with bed mobility, dressing, and personal hygiene. Resident #54 was totally dependent on staff for toilet use. However, Resident #54 was independent and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-03-15 · tag F0776 — isolatedProvide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
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 obtain radiology and other diagnostic services as physician ordered. This affected one (#215) out of two residents reviewed for radiology and diagnostic services. The facility census was 62. Findings include: Review of the medical record for the Resident #215 revealed an admission date of 11/16/21 and he was discharged to the hospital on [DATE]. Diagnoses included obesity, disorder of kidney and ureter, anemia, disease of the spinal cord, diabetes mellitus 2, essential primary hypertension, osteoarthritis, and spinal stenosis. Review of Resident #215's medical record revealed an dated 11/19/21 to obtain a hemoglobin A1C, complete blood count (CBC), basic metabolic panel (BMP) and B-type natriuretic peptide (BNP). Further review of Resident #215's medical record revealed there was no evidence of a hemoglobin A1C, CBC, BMP or BNP being obtained. Review of the admission Minimum Data Set (MDS) assessment, dated 11/23/21,…
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 before2022-03-15 · tag F0804 — failed to serve food at safe, palatable temperature — isolatedEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, staff and family interview and policy review, the facility to ensure ice cream was served at the appropriate temperature when the staff served ice cream that was foamy and melted. This affected one (#42) out of three residents reviewed for food temperature. The facility census was 62. Findings include: Record review for Resident #42 revealed an admission date of 12/27/17. Diagnosis included dementia with behavioral disturbance, asthma, major depressive disorder, [NAME] failure, anemia, anxiety disorder, essential primary hypertension, anemia, gastro-esophageal reflux disease, insomnia, dysphagia, chronic obstructive pulmonary disease. Review of the Resident #42's annual minimum data set (MDS) assessment dated , 01/24/22, revealed she had impaired cognition. Further review of the MDS assessment revealed Resident #42 required extensive assistance from staff with bed mobility, transfers, dressing, eating, and personal hygiene. Resident #42 was totally dependent on staff…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-03-15 · tag F0926 — failed to keep the home smoke-free / fire-safe — isolatedHave policies on smoking.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, staff and resident interview, and review of facility policy, the facility failed to implement their policy regarding assessing a resident for smoking safety. This affected one (#10) of two reviewed for smoking. The census was 62. Findings include: Review of Resident #18's medical record revealed an admission dated of 01/07/21. Diagnoses included cervical stenosis, insomnia, psychoactive substance abuse, cerebrovascular disease, and obstructive sleep apnea. Resident #18 was assessed as being cognitively intact and being independent with activities of daily living (ADL's). Review of Resident #18's careplan date 01/22/21 revealed Resident #18 was a supervised smoker. Staff were to complete a smoking assessment. Further review of Resident #18's medical record revealed a smoking assessment was last completed on 07/07/21. During an interview on 03/07/22 at 12:50 P.M. Resident #18 confirmed she smoked at the facility. Resident #18 stated she was a supervised smoker and thought that she should be an independent smoker. During an interview on 03/10/22 at 9:10…
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 · Fcited before2019-06-06 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and policy review, the facility failed to ensure biohazard materials were stored properly. This had the potential to affect all residents in the facility. The facility census was 76. During observation of the biohazard room behind the nursing station for the A and D halls on 06/05/19 at 8:40 A.M., three red three red bags containing biohazard materials were lying on the floor and not in the designated containers in the biohazard room. During interview at the time of the observation, Housekeeper #39 confirmed the findings. During interview on 06/05/19 at 3:12 P.M., the Administrator revealed all staff placing red biohazard bags in the biohazard room are to place the bags in the red plastic containers, the bags should not be left on the floor of the biohazard room. Review of the facility policy titled Hazardous Waste Access/Disposal Policy, dated September 2009, revealed housekeeping will monitor the hazardous waste receptacle in the waste rooms each day. Once the receptacle is full it will be removed from the floor and stored until the scheduled pick…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-06-06 · 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 interview and review of the resident fund management service (RFMS), the facility failed to ensure personal funds were not moved to the operational funds account. This affected one Resident (#61) of five reviewed for personal funds. The facility census was 63. Findings include: Closed record review revealed Resident #61 was admitted to the facility on [DATE] with diagnoses to include hypertension, diabetes, and dementia. Review of the nurse notes dated [DATE] revealed Resident #61 expired at the facility. Review of the RFMS statement dated from [DATE] to [DATE] revealed the account had debit and credit transactions after her death until the account was closed on [DATE]. On [DATE] there was a wire transfer amount of $902.00 back into the residents personal funds account. On [DATE] a check was sent to the funeral home for burial in the amount of $618.48. The account was closed on [DATE] with a balance of $64.92 which needed to be sent back to the state recovery. Interview on [DATE] at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-06-06 · tag F0569 — isolatedNotify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
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, and review of the resident fund management service (RFMS) the facility failed to timely convey personal funds after death. This affected one Resident (#61) of five reviewed for personal funds. The facility census was 63. Findings include: Closed record review revealed Resident #61 was admitted to the facility on [DATE] with diagnoses to include hypertension, diabetes, and dementia. Review of the nurse notes dated [DATE] revealed Resident #61 expired at the facility. Review of the RFMS statement dated from [DATE] to [DATE] revealed the account had debit and credit transactions after her death until the account was closed on [DATE]. On [DATE] there was a wire transfer amount of $902.00 back into the residents personal funds account. On [DATE] a check was sent to the funeral home for burial in the amount of $618.48 (The bill from the funeral home was dated [DATE]). The account was closed on [DATE] with a balance of $64.92 which needed to be sent back to the state recovery.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-06-06 · 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 record review, observation and interview, the facility failed to provide supervision for residents who required assistance to community doctor appointments. This affected one (Resident #42) of 18 residents reviewed. The facility census was 63. Findings included: Record review revealed Resident #42 was admitted to the facility on [DATE]. Diagnoses included macular degeneration, dementia and muscle spasms. Review of the minimum data set (MDS) assessment dated [DATE] documented no cognitive impairment. The resident required extensive assistance of one staff for locomotion on and off the unit and she had impaired vision. During interview on 06/05/19 at 8:39 A.M., Resident #42 stated she was sent out to an appointment sometime last week, which she was not supposed to go to, and she went by herself. During interview on 06/05/19 at 8:56 A.M., State Tested Nursing Assistant (STNA) #5 stated Resident #42 was going to the ear, nose and throat (ENT) doctor on 05/30/19. STNA #5 said she was off that day and did not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2024-07-11 · tag F0576 — widespreadEnsure residents have reasonable access to and privacy in their use of communication methods.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on resident and staff interviews and review of the resident right's handbook, the facility failed to ensure residents received mail on the weekends. This had the potential to affect all 63 residents residing in the facility. Findings include: Interviews on the annual survey on 07/08/24, 07/09/24, and 07/10/24 with Residents #18, #21, #27, #47, #52, and #53 revealed mail was not delivered on the weekends, only Monday through Friday. Interview on 07/11/24 at 10:49 A.M. with Business Office Manager (BOM) #155 revealed residents were supposed to receive mail on Saturdays except insurance related mail. BOM #155 reported the activities department was who passed out the mail. Interview on 07/11/24 at 11:13 A.M. with Activities Director #125 verified mail was not handed out on Saturdays, but only Monday through Friday. Review of the resident rights handbook revealed the resident had the right to send and receive mail, and to receive letters, packages, and other materials delivered to the facility for the resident thought a means other than a postal service including privacy of such…
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
No federal fines in the current CMS record.
Part of a chain
This home belongs to SABER HEALTHCARE GROUP — 126 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 | 2.9 | +0.1 vs chain |
| Health inspection | 3 of 5 | 2.6 | +0.4 vs chain |
| Staffing | 2 of 5 | 2.2 | -0.2 vs chain |
| Quality measures | 4 of 5 | 4.0 | ≈ chain avg |
The other 125 homes this chain runs (chain average 2.9★, per CMS)
Showing 40 of 125; lowest-rated first.
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 |
|---|---|---|---|
| VOLPE, BENJAMIN | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; ADP OF THE SNF | since 03/01/2019 |
| WEISBERG, WILLIAM | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 03/01/2019 |
| NICOLUZAKIS, GREGORY | Individual | CORPORATE OFFICER; ADP OF THE SNF | since 03/01/2019 |
| SABER GOVERNANCE LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/01/2019 |
| SHG MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/01/2019 |
| HOHLEFELDER, JASON | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/19/2022 |
| LUKEN, BETH | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/30/2023 |
| BENJAMIN N. VOLPE FAMILY DYNASTY TRUST (DATED DECEMBER 29, 2020) | Organization | ADP OF THE SNF | since 01/01/2023 |
| BNV DYNASTY LLC | Organization | ADP OF THE SNF | since 01/01/2023 |
| CITRIN COOPERMAN ADVISORS LLC | Organization | ADP OF THE SNF | since 12/01/2006 |
| DECANTED WILLIAM I. WEISBERG FAMILY DYNASTY TRUST (DATED SEPT 30, 2020 | Organization | ADP OF THE SNF | since 01/01/2023 |
| WILMINGTON RE GROUP, LLC | Organization | ADP OF THE SNF | since 01/05/2017 |
| WIW DYNASTY LLC | Organization | ADP OF THE SNF | since 01/01/2023 |
| INWOOD, MARY | Individual | ADP OF THE SNF | since 12/01/2006 |
CMS files one row per role, so the 22 rows in the source record cover these 14 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
8 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.
This home reported $1.3M paid to related parties — landlords or management companies under common ownership — equal to about 19% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. 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 365228. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-07-11, 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 →
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