Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 36 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
31D
3E
1F
Potential for minimal harm
0A
0B
0C
February 19, 2026Standard inspection · 5 citations
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident was shaved per preference upon admission to the facility and during first shower. This affected one resident (#54) of two residents reviewed for activities of daily living. The facility census was 48.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, staff, visitor and resident interview, review of the medical record and policy review, facility failed to ensure a newly identified skin impairment was assessed timely. This affected one resident (#9) of three residents reviewed for wounds. The facility also failed to ensure a change in condition was addressed timely. This affected one resident (#25) of one resident reviewed for change in condition. Facility census was 48.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record review, observation, interview, and policy review, the facility failed to ensure a resident at risk for pressure ulcers had pressure ulcer prevention interventions implemented as per their plan of care. This affected one resident (#2) of three residents reviewed for pressure ulcers.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, staff interview, and record review the facility failed to implement a fall risk intervention for a resident after a fall. This affected one resident (#4) of one resident reviewed for falls. The facility census was 48.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review and staff interview, the facility failed to ensure a resident receiving medication for hypotension did not receive the medications when his systolic blood pressure (SBP) was greater than 130 millimeters per mercury (mmHg), as per parameters included in his physician's orders. This affected one resident (#2) of five residents reviewed for unnecessary medications.
September 2, 2025Complaint inspection · 6 citations
- J
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on medical record review, hospital record review, wound notes, facility and staff interviews, wound physician interview, observation, review of the facility policies, and National Pressure Injury Advisory Panel (NPIAP) information, the facility failed to develop and implement an accurate comprehensive and individualized pressure ulcer program to ensure necessary care and services to prevent the worsening of pressure ulcers for Resident #800 and #300. This affected two residents (#800 and #300) of two residents reviewed for pressure ulcers. The facility census was 47. [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interviews and record reviews, the facility failed to appropriately manage and treat a non pressure skin alteration for one (Resident #100) out of two residents with non pressure skin alterations and obtain daily weights on three (Resident #100, #400 and #500) of three residents reviewed for daily weights. The facility census was 47.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on interview, record review and policy review, the facility failed to ensure residents had effective pain assessments and management. This affected three ( Resident #100, #300, and #800) of three residents reviewed for pain. The facility census was 47.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, medical record review, policy review and interview, the facility failed to ensure the facility medication administration error rate was not more than five percent. This affected one resident (#42) of eight residents observed for medication administration with four errors out of 25 opportunities resulting in an error rate of 16%. The census was 47.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interviews and record reviews, the facility failed to maintain an up to date and complete medical record for three residents (#100, #300 and #800) of three residents reviewed for receiving wound care from an outside wound consultant group. The facility census was 47.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and facility policy reviews, the facility failed to ensure proper hand hygiene and medical equipment was sanitized before and after resident use. This affected two residents (#701 and #802), but has the potential to affect all 47 residents residing in the facility.
November 14, 2024Standard inspection · 8 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, interview, and facility policy, the facility failed to ensure the ice machine was maintained in a sanitary manner. This had the potential to affect all 49 of the residents residing in the facility. The facility identified all 49 residents in the facility as receiving iced beverages from the main kitchen ice machine.
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on record review, observation, interview, and policy review, the facility failed to provide a homelike environment and ensure resident equipment was clean and well maintained. This affected four (#3, #13, #37, and #42) of four residents reviewed for environment. The facility census was 49.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, resident interview, staff interview, and policy review, the facility failed to ensure Resident #3 was treated with with dignity during and after dining. This affected one (Resident #3) of one resident reviewed for dignity. The facility census was 49.
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on record review, staff interview and facility policy, the facility failed to ensure that advanced directives were prominently placed in Resident #100's and Resident #149's medical records. This affected two (Resident #100 and Resident #149) of two residents reviewed for advanced directives. The facility census was 49.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observation, resident interview, staff interview, and policy review, the facility failed to ensure Resident #3 was provided with adaptive equipment for meals per physician orders. This affected one (Resident #3) of one resident reviewed for adaptive equipment. The facility census was 49.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record review, observations, interviews, review of facility policy, and review of equipment manuals, the facility failed to ensure alternating air mattresses were functional and set on the correct settings for pressure ulcer/injury prevention. This affected two (Resident #12 and Resident #13) of six residents reviewed for skin interventions. The facility census was 49.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on review of medical records, observation, and staff interview the facility failed to ensure fall interventions were in place for Resident #8 per the plan of care. This affected one resident (Resident #8) of two residents reviewed for falls. The facility census was 49.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to store respiratory equipment in a sanitary manner. This affected one (Resident #42) of one resident reviewed for respiratory equipment. The facility census was 49.
January 3, 2024Complaint inspection · 2 citations
- E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on review of the self-reported incident (SRI) and the facility's investigation, review of the facility policy, record review, and staff interviews, the facility failed to immediately report an allegation of staff-to-resident verbal abuse to the Administrator or designee. This affected one (Resident #27) of three residents reviewed for abuse. This had the potential to affect the six other residents (Resident #3, #16, #27, #35, #38, #39, and #40) who were identified by the facility to be on the Alleged Perpetrator's assignment on 10/06/23. The facility census was 40.
- E
Respond appropriately to all alleged violations.
Inspectors wroteBased on review of the self-reported incident (SRI) and investigation, review of the facility's policy, record review, and staff interviews, the facility failed to protect the other residents from potential abuse by not immediately removing State Tested Nursing Assistant (STNA) #150 from the facility after there was an allegation of verbal abuse to Resident #27. This affected one (Resident #27) of three residents reviewed for abuse. This had the potential to affect the six other residents (Resident #3, #16, #27, #35, #38, #39, and #40) who were identified by the facility to be on the STNA #150's assignment on 10/06/23. The facility census was 40.
August 10, 2023Standard inspection · 15 citations
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation and interview, the facility failed to ensure one resident (#9) was treated in a dignified manner. This affected one of one reviewed for dignity. The facility census was 44. Findings Included: Review of the medical record for Resident #9 revealed an initial admission date of 11/16/20 with the latest readmission of 08/23/21 with the diagnoses including hypertension, major depressive disorder, anxiety disorder, sleep apnea, chronic obstructive pulmonary disorder, osteoarthritis, obesity, fibromyalgia, full incontinence of feces, weakness, dysphagia, retention of urine, hyperlipidemia, atrial fibrillation, congestive heart failure, dyskinesia of esophagus, diverticulum of esophagus, diverticulosis of intestine, dysphagia, hypothyroidism, cerebral infarct, schizophrenia, dementia and gastro-esophageal reflux disease. [...]
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observations, record review, and resident and staff interviews, and facility policy review, the facility failed to ensure a resident's (Resident #18) call light was kept within reach. The deficient practice affected one resident (Resident #18) of one reviewed for call lights. The facility census was 44. Findings Include: Review of the medical record for Resident #18 revealed an admission date on 07/14/23. Medical diagnoses included Parkinson's Disease, generalized muscle weakness, nondisplaced Type II dens fracture (a bone in the spine), fracture of phalanx of right thumb, fracture of sacrum, and rheumatoid arthritis. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #18 had intact cognition and scored a 13 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. [...]
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on record review, interview and facility policy review, the facility failed to clarify conflicting code statuses for one resident (#20). This affected one of five residents reviewed for advance directives. The facility census was 44. Findings Include: Review of the medical record for Resident #20 revealed an initial admission date of 08/06/23 with the diagnoses including acute respiratory failure, abnormal posture, disorder of pituitary gland, vitamin D deficiency, major depressive disorder, anxiety disorder, chronic pain syndrome, chronic kidney disease, hypertension, dementia, cerebrovascular accident with hemiplegia, chronic obstructive pulmonary disease, diabetes mellitus, polyneuropathy, gastro-esophageal reflux disease, disorders of diaphragm, bilateral foot drop, colostomy status, osteoarthritis, bipolar disorder, contracture of left hand and contracture of left wrist. [...]
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on closed record review, staff interview, and facility policy review, the facility failed to notify one resident's (Resident #146) physicians when STAT (immediate) labs were not completed as ordered. The deficient practice affected one (Resident #146) of one reviewed for notification. The facility census was 44. Findings Include: Review of the closed medical record for Resident #146 revealed an admission date on 07/28/23. Resident #146 was sent out to the hospital and discharged from the facility on 08/07/23. Medical diagnoses included acute osteomyelitis left ankle and foot, sepsis, Type II Diabetes Mellitus with diabetic neuropathy, and Type II Diabetes Mellitus with foot ulcer. Review of the physician orders for August 2023 revealed Resident #146 had the following orders: [...]
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review, review of a Facility Reported Incident (FRI) investigation, staff interview, and facility policy review, the facility failed to report an allegation of physical abuse to the Ohio Department of Health (ODH) within two hours for one resident (Resident #35). The deficient practice affected one resident (Resident #35) of one reviewed for abuse. The facility census was 44. Findings Include: Review of the medical record for Resident #35 revealed an admission date on 12/09/21. Medical diagnoses included encephalopathy, cognitive communication deficit, Alzheimer's Disease, anxiety disorder, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #35 had severely impaired cognition. Resident #35 required extensive assistance from two staff to complete Activities of Daily Living (ADLs). [...]
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on record review and interview, facility failed to submit a new Pre-admission Screening/Resident Review (PASRR) once a resident received a new diagnosis of major depressive disorder. This affected one (Resident #37) of two residents reviewed for PASRR. The census was 44.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on record review, observation, interview, and policy review, the facility failed to ensure showers were completed for Resident #37 and failed to ensure toenail care was completed for Resident #18. This affected two (Resident #18 and #37) of two residents reviewed for activities of daily living (ADL). The facility census was 44.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure one resident (Resident #18) had a soft cervical collar placed when out of bed as ordered. Additionally, the facility failed to timely complete initial comprehensive wound assessments for one resident's (Resident #146) surgical wounds. The deficient practices affected two residents (Residents #18 and #146) of two residents reviewed for quality of care. The facility census was 44. Findings Include: 1. Review of the medical record for Resident #18 revealed an admission date on 07/14/23. Medical diagnoses included Parkinson's Disease, nondisplaced Type II dens fracture (a bone in the spine), fracture of phalanx of right thumb, fracture of sacrum, and rheumatoid arthritis. [...]
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to timely complete initial comprehensive assessments of identified pressure injury areas for one resident (Resident #146). The deficient practice affected one resident (Resident #146) of three residents reviewed for pressure ulcers. The facility census was 44. Findings Include: Review of the closed medical record for Resident #146 revealed an admission date on 07/28/23. Resident #146 was sent out to the hospital and discharged from the facility on 08/07/23. Medical diagnoses included acute osteomyelitis left ankle and foot, sepsis, Type II Diabetes Mellitus with diabetic neuropathy, and Type II Diabetes Mellitus with foot ulcer. [...]
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on record review, observations, resident and staff interviews, and facility policy review, the facility failed to complete timely incontinence care and toileting assistance for two residents (Residents #9 and #18). The deficient practice affected two residents (Residents #9 and #18) of two reviewed for bowel and bladder. The facility census was 44. Findings Include: 1. Review of the medical record for Resident #18 revealed an admission date on 07/14/23. Medical diagnoses included Parkinson's Disease, nondisplaced Type II dens fracture (a bone in the spine), fracture of phalanx of right thumb, fracture of sacrum, and rheumatoid arthritis. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #18 had intact cognition and scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. [...]
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, record review, interview and facility policy review, the facility failed to ensure one resident (#34) received timely meal assistance. The facility also failed to ensure one resident's (#18) fluids were accessible. Additionally the facility failed to provided one resident (#9) the physician ordered two handled cup with meals. This affected one ( Resident #34) of one resident reviewed for nutrition, one ( Resident #18) of one resident received for hydration and one ( Resident #9) of 13 sampled residents. The facility census was 44. Findings Include: 1. [...]
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on record review and interview, the facility failed to address pharmacy recommendations within thirty days and did not follow up on recommended labs. This affected three (Resident #9, #10, and #28) of three residents reviewed for medication regiment reviews. The facility census was 44.
- D
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.
Inspectors wroteBased on observation and interview, the facility facility to ensure medications were properly stored and labeled. This affected Resident #20 using the Lantus insulin pen and had the potential to affect 27 residents (#1, #2, #4, #5, #7, #9, #10, #11, #13, #14, #17, #19, #20, #21, #22, #25, #26, #27, #29, #30, #34, #36, #37, #38, #40, #76 and #94) who reside on the 100 unit. The facility census was 44. Findings Include: 1. On 08/10/23 at 3:05 P.M., observation of the 100 unit medication cart revealed one Lantus insulin pen laying in the drawer with no name or date on the insulin pen. The Lantus insulin pen had been pulled from the emergency drug kit (EDK). Further observation revealed a Lispro Insulin pen laying in the drawer with no name or date on the insulin pen. The Lispro insulin pen was also pulled from the EDK. [...]
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on medical record review, review of lab results, staff interview, and review of the facility laboratory agreement, the facility failed to obtain STAT (immediate) labs as ordered for one resident (Resident #146). The deficient practice affected one resident (Resident #146) of one reviewed for laboratory testing. The facility census was 44. Findings Include: Review of the closed medical record for Resident #146 revealed an admission date on 07/28/23. Resident #146 was sent out to the hospital and discharged from the facility on 08/07/23. Medical diagnoses included acute osteomyelitis left ankle and foot, sepsis, Type II Diabetes Mellitus with diabetic neuropathy, Type II Diabetes Mellitus with foot ulcer, and chronic kidney disease stage 3b. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, interview and facility policy review, the facility failed to maintain infection control practices in the manner to prevent the potential spread of infection in the area of pressure ulcer dressing change and catheter care. This affected one resident (#20) of two residents reviewed for pressure ulcers and one resident (#37) of one resident reviewed for catheter. The facility census was 44. Findings Include: 1. [...]
Fire safety inspections
9 fire safety citations on file: 2 on February 19, 2026, 2 on November 14, 2024, 2 on March 28, 2024, 3 on August 10, 2023.
Every fire safety citation9 citations
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · February 19, 2026 · deficient, provider has
- F
Have an externally vented heating system.
K 522 · February 19, 2026 · Corrected (the home has a date of correction)
- F
Use approved construction type or materials.
K 161 · November 14, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · November 14, 2024 · Corrected (the home has a date of correction)
- F
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · March 28, 2024 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · March 28, 2024 · Corrected (the home has a date of correction)
- E
Install a fire alarm system that can be heard throughout the facility.
K 341 · August 10, 2023 · Waiver
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 10, 2023 · Corrected (the home has a date of correction)
- E
Have properly sized and located compartments to protect residents from smoke.
K 371 · August 10, 2023 · Waiver