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Shepherd Of The Valley-Boardman

7148 West Blvd, Youngstown, OH 44512 · Non profit - Corporation · 57 certified beds · (330) 726-9061 Medicare & Medicaid certified

Call the home — (330) 726-9061 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Dec 20251 actual-harm citation
Insights

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

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its independent health-inspection rating is low (2/5)
  • nursing-staff turnover (67%) runs well above the national median (45%)

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.

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

Location & what’s nearby

Hospital
★★★★ 4/5 CMS
Urgent care / clinic
7087 West Blvd · (330) 758-8183 · Call to confirm hours
Pharmacy
685 Boardman Canfield Rd · (888) 222-6185 · Call to confirm hours
Grocery
476 Boardman-Canfield Road
Park
6900-7298 Pinewood Dr · Typically dawn to dusk
Place of worship
7155 Glenwood Ave · (330) 953-2100

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 3 of 5
Long-stay residentspeople who live here 3 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 fell from 5 to 2 stars. From monthly CMS archive snapshots.

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

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased17.5%5.3%15.4%worse than state — see note marked double-dagger below the table
Long-stay residents who lose too much weight5.9%6.2%5.4%typical
Long-stay residents with a catheter left in their bladder1.5%0.2%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection3.2%0.4%2.0%worse than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms0.9%30.1%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury1.6%3.2%3.3%better
Long-stay residents whose ability to walk worsened31.4%6.1%16.1%worse than state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication21.6%25.5%18.9%worse
Long-stay residents given the seasonal flu vaccine94.1%94.5%95.3%typical
Long-stay residents with pressure ulcers6.3%3.4%4.7%worse
Long-stay residents with worsening bladder/bowel control30.7%21.4%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table8.2%8.8%17.1%better
Short-stay residents who newly got an antipsychotic medication1.4%1.2%1.4%typical
Short-stay residents given the seasonal flu vaccine64.2%75.6%79.4%worse
Short-stay residents rehospitalized after admission25.9%24.9%22.6%worse
Short-stay residents with an outpatient ER visit9.4%12.9%12.0%better

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

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

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

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

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

57.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 79 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

57.5%U.S. median 51.5%
Got home and stayed home
11.3%U.S. median 10.7%
Went back to hospital
53.3%U.S. median 56.6%
Met the expected recovery
0.53U.S. median 0.31
Therapy hours / resident / day
0.21hours / resident / day
Physical therapy
0.25hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 53.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 30 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.53 therapist hours per resident per day in 2026Q1 — more than 83% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 19% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF57.5%CMS range 48.2–67.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.3%CMS range 7.8–15.310.7%Oct 2022–Sep 2024no 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 discharge53.3%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge30.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge60.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened6.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.6%CMS range 4.5–14.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.911.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.58
RN hours/ resident / day
1.29
LPN hours/ resident / day
2.17
Aide hours/ resident / day
4.04
Total nurse hours/ resident / day
0.28
RN hoursweekends
66.7%
Total nursing turnover
62.5%
RN turnover

How full it usually is: this home is certified for 57 beds and averages 44.3 residents a day — about 78% occupied, or roughly 13 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.04 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.58 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.17 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.29 hrs/resident/day on weekends vs 4.34 on weekdays — 24% thinner on weekends — a notable drop. RN hours go from 0.70 to 0.28 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 67% is well above the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

18
deficiencies at the latest standard inspection (2025-12-31)
0
at the previous standard inspection (2023-03-23)

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.

ABCDEFGHIJKL

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

24 citations, most serious first. The 11 most serious are shown; the remaining 13 are one tap away and print in full.

  • Actual harm · Gcited before2025-12-31 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview and review of facility policy, the facility failed to implement an effective pressure ulcer prevention program to promote healing and to ensure Resident #51, who was cognitively impaired, dependent on staff for hygiene and had functional limitation to bilateral upper extremities, received interventions to prevent skin breakdown, timely assessments to her right third and fourth finger wounds and wound care as ordered by the physician.Actual Harm occurred on 10/08/25 when Resident #51 was assessed by Nurse Practitioner (NP) #301 and found to have long nails on her right hand digging into her hand causing wounds (no size or wound type provided in documentation). On 10/09/25 Licensed Practical Nurse (LPN) #205 attempted to assess and cleanse Resident #51's right hand, however, the resident refused. LPN #205 stated she would again approach the resident after lunch, however, there was no evidence that Resident #51's right hand was assessed. There were no further nurse…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-12-31 · tag F0761 — failed to label and store drugs safely — widespread
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and facility policy review the facility did not ensure medications were not stored expired and were stored securely in medication storage areas. This affected four of four medication carts observed and had the potential to affect all residents in the facility. The facility census was 49.Findings include: 1. An observation on [DATE] at 10:00 A.M. of the 300 Hall medication cart revealed the following: an opened bottle of Geri-Care acetaminophen (a non-narcotic pain medication) 1000 milligram (mg) tablets with an expiration date of 11/2025, two packets of Medline 0.9 ounce (oz) lubricating jelly with an expiration date of 08/2022, two packets of Medline 0.9 oz lubricating jelly with an expiration date of [DATE], a packet of Medline 0.9oz lubricating jelly with an expiration date of [DATE], two Medline povidone iodine (a topical skin antiseptic) 10% swab sticks with an expiration date of 10/2024, a Medline povidone iodine 10% with an expiration date of 02/2025, a Medline…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-12-31 · tag F0638 — pattern
    Assure that each resident’s assessment is updated at least once every 3 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, interview, and review of the Long-Term Care Resident Assessment Instrument (LTC RAI) 3.0 User's Manual, the facility failed to complete non-comprehensive Minimum Data Set (MDS) assessments in a timely manner. This affected four residents (#2, #8, #25, and #26) out of four residents reviewed for non-comprehensive resident assessments. The facility census was 49.Findings include:1. Review of the medical record for Resident #2 revealed an admission date of 11/03/20 with diagnoses including cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, hypertension, altered mental status, and dysphagia. On 12/16/25 at 11:28 A.M., review of the quarterly MDS assessment with an Assessment Reference Date (ARD) of 11/28/25 revealed it had not yet been completed. Sections A, B, C, GG, I, J, L, N, O, and S had not been completed. On 12/16/25 at 12:23 P.M., an interview with Regional MDS Nurse #204 verified Resident #2's quarterly MDS assessment had an ARD date of 11/28/25 and it had not yet been completed. On 12/16/25 at…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-12-31 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview and review of facility policy, the facility failed to ensure accurate documentation in the medical records for Resident #4, #8, #47 and #51. This affected four residents (Residents #4, #8, #47 and #51) out of 25 residents reviewed for resident records. The facility census was 49. Findings include:1. Review of the medical record for Resident #51 revealed an admission date of 02/21/23 with diagnoses including diabetes mellitus, congestive heart failure, peripheral vascular disease and contracted hands. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #51 had impaired cognition. Review of the wound assessment dated [DATE] by Licensed Practical Nurse (LPN) #302, who was also the facility ' s skin nurse, revealed Resident #51 had an Unstageable Pressure Ulcer (full-thickness tissue loss with the base of the ulcer covered by slough (yellow, tan, gray, green or brown) or eschar (tan, brown or black) in the wound bed) to her right…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-31 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of 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 record review, observation and interview, the facility failed to ensure call lights were within reach for Resident #44 and Resident #30. This affected two residents (#44 and #30) out of two residents reviewed for call lights. The facility census was 49.Findings include:1. Review of the medical record revealed Resident #44 was admitted to the facility on [DATE] with diagnosis including stroke, respiratory failure, dysphagia (difficulty swallowing), aphasia (a language disorder due to brain damage), hemiplegia (one-sided paralysis or weakness), hemiparesis (paralysis on one side of the body), and malnutrition. Review of the care plan dated 07/03/25 revealed Resident #44 was at risk for falls with an intervention to keep the call light within reach.Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #44 was moderately cognitive impaired, had upper limb impairment on one side, required maximal assistance or was completely dependent on staff for care needs, did not reject care,…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-31 · tag F0563 — failed to protect the right to visitors — isolated
    Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, interview, review of the resident handbook and facility policy review, the facility failed to honor visitors per the preference of Resident #63. This affected one resident (#63) of one resident reviewed for visitation. The facility census was 49.Findings include:Review of the medical record for Resident #63 revealed an admission date of 08/07/25 with diagnoses including sepsis, chronic kidney disease and malignant neoplasm (cancer) of the prostate.Review of the nursing progress note dated 09/30/25 at 3:54 P.M. for Resident #63 revealed a plan of care meeting was held with the resident and his son. The facility offered hospice care and discussed Resident #63's decline in status.Review of the text message dated 10/26/25 at 8:31 A.M. sent from Licensed Practical Nurse (LPN) #207 to Regional Staff Educator #208. LPN #207 stated she was instructed by the facility's staff aide that family were not permitted to spend the night in the building. She stated she was updating her as Resident #63's son had spent the previous night (10/25/25 into 10/26/25) with his father.…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-31 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, review of the facility investigation and facility policy review, the facility failed to report an allegation of misappropriation to the State Agency for Resident #17. This affected one resident (#17) of two residents reviewed for misappropriation. The facility census was 49.Findings include:Review of the medical record for Resident #17 revealed an admission date of [DATE] with diagnoses including fractures of the left tibia and fibula, multiple sclerosis, diabetes and dependence on renal dialysis. Resident #17 expired at the hospital on [DATE] at 10:07 A.M.Review of the physician's orders for [DATE] for Resident #17 revealed an order for Hydrocodone-Acetaminophen (narcotic pain medication) 5-325 milligrams (mg), one tablet every six hours as needed for pain dated [DATE]. This order was discontinued on [DATE] at 3:14 P.M.Review of the Medication Administration Record (MAR) for [DATE] for Resident #17 revealed she had received her last dose of Hydrocodone-Acetaminophen 5-325 mg…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-31 · tag F0636 — isolated
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, interview, and review of the Long-Term Care Resident Assessment Instrument (LTC RAI) 3.0 User's Manual, the facility failed to complete significant change Minimum Data Set (MDS) assessments in a timely manner for Residents #11 and #15. This affected two residents (#11 and #15) out of three residents reviewed for comprehensive resident assessments. The facility census was 49.Findings include:1. Review of the medical record for Resident #11 revealed an admission date of 03/08/20 with diagnoses including chronic obstructive pulmonary disease, bladder cancer, major depressive disorder, congestive heart failure, and atrial fibrillation. Resident #11 was admitted to hospice services on 11/06/25. On 12/16/25, review of the significant change MDS assessment with an Assessment Reference Date (ARD) of 11/14/25 revealed it had not yet been completed. Sections A, B, C, GG, I, J, L, N, O, S, and V had not been completed. On 12/16/25 at 12:23 P.M., an interview with Regional MDS Nurse #204 verified Resident #11's significant change MDS assessment had an ARD date 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-31 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure resident assessments were accurately completed. This affected two residents (#25 and #51) of 25 residents' assessments reviewed. The facility census was 49.Findings include:1. Review of the medical record for Resident #51 revealed an admission date of 02/21/23 with diagnoses including diabetes mellitus, congestive heart failure, chronic pain, peripheral vascular disease, hypertension and anxiety. Review of the physician's orders for Resident #51 revealed she had an order for Hydrocodone-Acetaminophen 5-325 milligrams (mg) every six hours as needed for pain dated 07/15/24. Review of the Medication Administration Record (MAR) for October 2025 for Resident #51 revealed she had received Hydrocodone-Acetaminophen 5-325 mg for pain on 10/01/25 at 1:00 A.M. and 8:50 P.M., on 10/03/25 at 8:53 A.M., on 10/04/25 at 1:40 P.M. and 8:44 P.M., and on 10/05/25 at 6:02 A.M. and 8:44 P.M. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-31 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to timely update care plans to address changes in a resident's condition. This affected one resident (#51) of 25 resident care plans reviewed. The facility census was 49.Findings include:Review of the medical record for Resident #51 revealed an admission date of 02/21/23 with diagnoses including diabetes mellitus, congestive heart failure, peripheral vascular disease and contracted hands. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #51 had impaired cognition.Review of the wound assessment dated [DATE] by Licensed Practical Nurse (LPN) #302, who is also the facility's skin nurse, revealed Resident #51 had an unstageable pressure ulcer (full-thickness tissue loss with the base of the ulcer covered by slough (yellow, tan, gray, green or brown) or eschar (tan, brown or black) in the wound bed) to her right second and third fingers (documentation error as it should be third and fourth fingers) and these were…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-31 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations, interview and review of the facility policies, the facility failed to ensure Resident #44 received needed assistance with activities of daily living (ADL). This affected one resident (#44) out of five residents reviewed for ADL. The facility census was 49.Findings include:Review of the medical record revealed Resident #44 was admitted to the facility on [DATE] with diagnosis including stroke, respiratory failure, dysphagia (difficulty swallowing), aphasia (a language disorder due to brain damage), hemiplegia (one-sided paralysis or weakness), hemiparesis (paralysis on one side of the body), and malnutrition.Review of the care plan revealed Resident #44 had a potential for alteration in skin integrity due to fragile skin dated 06/17/25 with an intervention to keep the resident's nails short and clean.Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #44 was moderately cognitively impaired, had upper limb impairment on one side, was dependent…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 13 citations
  • Potential for harm · D2025-12-31 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview and facility policy review, the facility failed to ensure Resident #51 splint was implemented and utilized as ordered and failed to ensure Resident #44 had a physician's order for the splint observed on his left arm. This affected two residents (#51 and #44) of two residents reviewed for splint usage. The facility census was 49.Findings include:1. Review of the medical record for Resident #51 revealed an admission date of 02/21/23 with diagnoses including diabetes mellitus, congestive heart failure, peripheral vascular disease and contracted hands. Review of Resident #51's care plan dated 05/21/24 revealed she had limited physical mobility related to contractures and weakness. Interventions included for staff to monitor, document and report as needed any signs or symptoms of immobility, contractures forming or worsening, thrombus formation, skin breakdown and fall related injury, referrals to physical therapy and occupational therapy as ordered and needed as well as…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-31 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview and facility policy review, the facility failed to ensure a re-admission assessment and new fall prevention interventions were timely implemented after a four-day hospitalization post-fall with injury and failed to ensure fall prevention interventions were in place for Resident #30. This affected one resident (#30) out of one resident reviewed for accidents. The facility census was 49.Findings include:Review of the medical record revealed Resident #30 was admitted on [DATE] with diagnoses including dependence on renal dialysis, weakness, end stage renal disease, spinal stenosis, congestive heart failure, and dysphagia.Review of the care plan dated 05/30/25 revealed Resident #30 was at risk for falls/injury related to gait/balance problems and psychoactive drug use. Interventions included adequate lighting, appropriate shoes/nonslip socks, assess/monitor for side effects from psychoactive medications such as lethargy, maintain clear pathways, provide frequent…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-31 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    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, interview and review of the facility policy, the facility failed to establish and implement physician's orders for tube feed administration for Resident #9 and failed to check tube feed residuals prior to medication administration for Resident #44. This affected two residents (#9 and #44) out of two reviewed for enteral feedings. The facility census was 49. Findings include:1. Review of the medical record for Resident #9 revealed an admission date of 06/23/25 with diagnoses including gastrointestinal hemorrhage, angiodysplasia of colon, dementia, gastrostomy status, dysphagia, and adult failure to thrive. Review of the enteral feeding care plan dated 06/23/25 indicated Resident #9 required a tube feeding due to resisting eating and swallowing problems. Interventions included monitoring and documenting signs or symptoms of intolerance to tube feeding (initiated 06/23/25), Registered Dietitian to evaluate quarterly and as needed (initiated 06/23/25), and tube feeding of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-31 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and review of facility policy, the facility failed to ensure post dialysis assessments were completed as required. This affected one resident (#30) out of one resident reviewed for dialysis. The facility census was 49.Findings include:Findings include:Review of the medical record revealed Resident #30 was admitted to the facility on [DATE] with diagnoses of dependence on renal dialysis, heart failure, and weakness. Review of the Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #30 had fractures and other trauma, was cognitively intact, was dependent on facility staff for toileting, required moderate assistance for transfers, was frequently incontinent of bowel and bladder, required hemodialysis, and did not reject care. Review of the physician orders revealed an order dated 10/09/25 to check vital signs and dialysis access site upon completion of dialysis as needed and an order dated 10/09/25 to check vital signs and dialysis access site upon completion of dialysis…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-31 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure all controlled medication accounting logs were reconciled after/before each shift as well as ensuring medications were accurately reflected on the Medication Administration Records (MAR) and controlled medication accounting logs in the resident's medical record. This affected three (Residents #17, #45 and #51) of three reviewed for controlled medication usage. The facility census was 49. Findings include: 1. Review of the Narcotic Count Sheets (which detail and track controlled substances including the receipt, use, disposal and transfer of controlled substances) revealed the nurse going off shift was to document the time, shift, number of controlled medication cards, number of controlled count sheets, if they received any medications during their shift, disposed of any medications during their shift and sign. The incoming nurse would then verify the controlled medication cards and count sheets, document the time and sign their name. 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-31 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, interviews, and review of facility policy, the facility failed to ensure Resident #51 was free of significant medication errors. This affected one resident (Resident #51) of nine residents reviewed for medication administration. The facility census was 49. Findings include: Review of the medical record for Resident #51 revealed an admission date of 02/21/23 with diagnoses including diabetes mellitus, congestive heart failure, schizophrenia, peripheral vascular disease, hypertension and anxiety. Review of the physician ' s orders for Resident #51 revealed orders for Dextromethorphan-Bupropion ER (medication for major depressive disorder) 45-105 milligrams (mg) in the morning dated 06/04/25; Hydralazine HCL (medication for high blood pressure) 50 mg three times daily dated 06/04/25; Hydroxyzine HCL (medication for anxiety) 25 mg three times daily dated 06/15/25; Pancrelipase (medication used to treat exocrine pancreatic insufficiency which is a condition where the pancreas does not produce enough digestive enzymes) 24,000-76,000 units three times daily dated…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-31 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure urinary catheter bags were placed in a manner to prevent contamination and risk of infection for Resident #43. This affected one resident (#43) of one resident reviewed for catheter care. The facility census was 49.Findings include: Review of the medical record for Resident #43 revealed an admission date of 01/15/25 with diagnoses including vascular dementia, benign prostatic hyperplasia with lower urinary tract symptoms, hematuria, and neuromuscular dysfunction of the bladder. Review of the care plan, date initiated 02/03/25, revealed Resident #43 was at risk for urinary retention, painful urination, and frequent urination due to a diagnosis of benign prostatic hyperplasia and had an indwelling catheter due to urinary retention. Interventions included foley catheter and follow catheter care per orders or policy, check tubing for kinks, monitor and document intake and output, monitor for signs or symptoms of discomfort with urination and…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-19 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure wound treatments were competed per physician orders for Resident #24. This effected one resident (Resident #24) out of three residents reviewed for wound care. The facility census was 42. Findings include: Review of the medical record for Resident #24 revealed an admission date of 12/05/22 with diagnoses including sepsis, orthostatic hypotension, anemia, dysphagia, type two diabetes mellitus, sacral wound, dementia, chronic kidney disease, and spinal stenosis of the lumbar region. Review of Resident #24's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition. They required partial to moderate assistance with eating and upper body dressing. They required substantial to maximal assistance with oral hygiene, personal hygiene, and bed mobility. Additionally, they were dependent on staff for showers, toileting hygiene, bed mobility and transfers with a full lift by two 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-19 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and review of facility policy, the facility failed to ensure weights were obtained per physician orders for residents receiving dialysis treatment. This effected three residents (Residents #22, #34, and #35) of three residents reviewed for dialysis. The facility identified eight residents (#22, #34, #35, #36, #37, #39, #42 and #43) as receiving dialysis treatment. The facility census was 42. Findings include: 1. Review of the medical record for Resident #22 revealed an admission date of 05/01/24 with diagnoses including pleural effusion, dependence on renal dialysis, and endstage renal disease. Review of Resident #22's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had cognitive impairment. They required setup assistance with eating, supervision with oral hygiene, and bed mobility, they required substantial to maximal assistance with dressing and was dependent for toileting hygiene, showers, and personal hygiene. Review of Resident #22's care…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-12 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, medical record review, and review of the facility policy, the facility failed to ensure appropriate hand hygiene was performed during medication administration for Residents #21 and #44 and failed to ensure appropriate identification of resident transmission-based precautions status for Resident #44. This affected two residents (#21 and #44) of three residents who were observed during medication administration and had the potential to affect all 41 residents resining in the facility. Findings include: 1. Review of the medical record for Resident #21revealed an initial admission date of 08/10/24 and a re-entry date of 11/06/24. Diagnoses included acute and chronic respiratory failure with hypoxia, active COVID-19 infection upon initial admission, chronic obstructive pulmonary disease (COPD), asthma, and presence of a cardiac pacemaker. Review of the most recent comprehensive Minimum Data Set (MDS) assessment completed on 09/07/24 revealed Resident #21 had intact cognition. High-risk medications included antidepressants, antibiotics, and antiplatelets.…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-01 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not ensure Resident #40 received a post-surgical follow up visit with her surgeon in a timely manner. This affected one resident (Resident #40) of three residents reviewed for hospitalization. The facility census was 39. Finding include: Record review for Resident #40 revealed she was admitted to the facility on [DATE] for post-surgical aftercare and rehabilitation following spinal surgery on 05/05/23. Her list of diagnoses upon admission included sepsis, type two diabetes mellitus, spinal stenosis, cirrhosis of the liver, chronic kidney disease stage three, history of bacteremia, multidrug resistant organisms, urinary tract infection, splenial megaly, anemia and hypothyroidism. Resident #40 was discharged to the hospital on [DATE] at the request of her family for an evaluation. Review of physician orders from 05/09/23 to 05/26/23 revealed an order for the facility to call Resident #40's surgeon's office on 05/10/23 to set up a follow-up appointment as soon…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2019-10-31 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview the facility failed to maintain the services of a registered nurse (RN) for at least eight (8) consecutive hours a day, seven (7) days per week. This had the potential to affect all 40 residents residing in the facility. Findings include: Review of the staffing schedule from 10/01/19 through 10/28/19 revealed there was no RN coverage for at least eight consecutive hours on 10/12/19, 10/13/19, 10/26/19 or 10/27/19. On 10/30/19 at 4:00 P.M., interview with RN #400 verified the above finding. This deficiency substantiates Complaint Number OH00107669.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-10-31 · tag F0881 — failed to use antibiotics responsibly — isolated
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to implement an effective antibiotic (ATB) stewardship program to ensure the proper use of antibiotics. This affected two residents (#31 and #12) residents residing in the facility. Findings include: 1. Resident #31 was admitted to the facility on [DATE] with a diagnosis which included pancreatic cancer. Review of a nursing note, dated 07/23/19 revealed the resident did not have any signs and/or symptoms (s/s) of a urinary tract infection (UTI). Further review revealed the Hospice nurse recommended a urinalysis. Review of the physician's orders, dated 07/25/19 revealed an order to obtain a urinalysis. Review of the urinalysis results received 07/29/19 revealed the resident had one organism present. Review of the physician's orders, dated 07/29/19 revealed an order to start an ATB, Ampicillin 500 milligrams (mg) three times a day (TID) for seven days, for a urinary tract infection. Further review of the medication administrator record (MAR) from 07/29/19…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleSince
ADAMIC, PAULIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICERsince 06/20/2022
FILIP, CHRISITNEIndividualW-2 MANAGING EMPLOYEEsince 10/19/2008
LIMONGI, RICHARDIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICERsince 01/01/1993
PARISH, CORYIndividualW-2 MANAGING EMPLOYEEsince 09/08/2015
DEABATE, GIUSEPPEIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 01/01/2019
EARNHEARDT, ADAMIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 01/01/2020
QUAINTANCE, ROBERTIndividualCORPORATE DIRECTORsince 01/01/2023
THOMPSON, RICHARDIndividualCORPORATE DIRECTORsince 01/01/2019

CMS files one row per role, so the 12 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

Follow the money — this home’s finances

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

$4.5M
Net patient revenuemost recent cost report
-21.9%
Operating marginrevenue minus expenses
$428K
Related-party expense8% of expenses
Who pays — share of resident-days
Medicaid 14%Medicare 8%Other / private 77%

This home reported $428K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$371per resident / day
operating cost
$11,274per month
≈ monthly operating cost
$304per day
avg. revenue, all payers

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

What families pay in OH

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 365580. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-31, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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