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 45 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
29D
3E
8F
Potential for minimal harm
0A
1B
4C
April 21, 2026Complaint inspection · 3 citations
- F
Have a plan that describes the process for conducting QAPI and QAA activities.
Inspectors wroteBased on review of prior survey activity, review of the facility's plan of correction and audits, and interview, the facility failed to ensure efforts were made to meet compliance with the regulatory requirements, solely focusing on the exact cited issue. This had the potential to affect all 80 residents. Review of a survey activity report from a complaint survey (with an exit date of 04/21/26) revealed the facility received a citation related to pharmacy services when the facility failed to reconcile narcotic medications delivered from the pharmacy with the pharmacy delivery slips to ensure the facility received all the listed narcotic medications. Review of the facility's plan of correction revealed the facility's focus on reaching compliance was focused on ensuring the accounting for receipt of a specific narcotic medication (fentanyl patches). [...]
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on review of the medical record and interview with staff and residents, the facility failed to ensure showers for Resident #1, who was dependent for activities of daily living, were completed as scheduled. This affected one resident (Resident #1) of three reviewed for bathing. The facility census was 82.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on the review of the medical record, review of the Self-Reported Incident, review of pharmacy delivery slips, and interview with the staff, the facility failed to reconcile narcotic medications delivered from the pharmacy with the pharmacy delivery slip upon delivery to the facility to ensure the facility received all the listed narcotic medications. This affected one resident (Resident #69) of three residents reviewed for delivery of medication. The facility census was 82.
March 24, 2026Standard inspection, Complaint inspection · 34 citations
- F
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on observations, review of the staffing policy, and residents, family, and staff interviews, the facility failed to ensure there was sufficient staff to meet residents' needs in a timely manner. This affected six residents observed during the survey (#22, #31 #34, #45, #52, and #75). This had the potential to affect all 73 residents residing in the facility.
- F
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.
Inspectors wroteBased on record review and interview the facility failed to ensure there was a Registered Nurse providing services at least eight hours a day, seven days a week. This had the potential to affect all 80 residents residing in the facility. Facility census was 80.
- F
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, interview, record review, and review of the facility policy, the facility failed to ensure medications were stored in a safe and secure manure and failed to ensure medications were not expired. One medication room and three medications carts were observed. The facility identified there was one medication room and six medication carts. This had the potential to affect all 73 residents residing at the facility.
- F
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Inspectors wroteBased on observations, resident and staff interviews, and review of the facility policy, the facility failed to provide substantial nutritional evening snacks when meals times were greater than 14 hours. This had the potential to affect all 73 residents who receive meals from the kitchen. The facility census was 73.
- F
Have a plan that describes the process for conducting QAPI and QAA activities.
Inspectors wroteBased on record review and staff interviews, the facility failed to timely implement its Quality Assurance Performance Improvement (QAPI) corrective actions for identified regulatory deficiencies. This had the potential to affect all 73 residents residing in the facility.
- F
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on document review and interview, the facility failed to conduct quality assurance committee meetings a minimum of quarterly. This had the potential to affect all 73 residents.
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interview, record review, review of the facility policies and Manufacturer guidelines, the facility failed to ensure infection control practices were maintained for three residents (Resident #60, #83 and #86) observed during medication administration, two residents (Resident #2 and #83) observed during blood sugar assessments, one resident (Resident #22) observed for Enhanced Barrier Precautions, one resident (Resident #85) observed with soiled linen on the floor. Additionally, the facility failed to ensure water testing was routinely completed for Legionella. This affected six residents (#2, #22, #60, #83, #85, and #86) and had the potential to affect all residents residing in the facility. The facility census was 73.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, interview, record review and policy review, the facility failed to ensure residents received timely assistance with meals and received showers per schedule. This affected three residents (Resident #22, #34 and #75) of five residents reviewed for assistance during mealtimes and one resident (Resident #37) of three residents reviewed for being offered showers per schedule. The facility census was 73. Findings Include: 1. Review of the medical record for Resident #22 revealed an admission date 07/01/21. Diagnosis included dementia, difficulty in walking, chronic kidney disease stage 3, anxiety, on hospice and solitary pulmonary nodule. Review of the significant change Minimum Data Set (MDS) dated [DATE] revealed impaired cognition. Resident #22 required substantial/maximal assistance for eating and dependent for all other activities of daily living (ADL's). [...]
- E
Provide activities to meet all resident's needs.
Inspectors wroteBased on observations, interviews, record review and policy review the facility failed to ensure residents were offered activities to meet their interests and support psychosocial well-being. This affected four residents (Resident #22, #30, #31 and #57) of four residents reviewed for activities. The facility census was 73.
- E
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on staff interviews and record review, the facility failed to ensure the residents received nutritional supplements as physician ordered and failed to ensure the amount of fluid offered/consumed was documented when there was a physician order to encourage fluid intake for a resident. This affected two (Residents #4 and #37) of two residents reviewed for nutrition. This had the potential to affected an additional nine residents the facility identified who had physician orders to receive a nutritional supplement named Ensure. The facility census was 73.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on medical record review and interview, the facility failed to ensure residents and/or responsible parties were informed of the risk of antipsychotic use prior to administration. This affected two (Residents #48 and #88) of six residents reviewed for medication use. The facility census was 73.
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on observations, medical record review, and interview, the facility failed to permit a resident to choose dining location and times. This affected one (Resident #31) of four residents reviewed for choices. The facility census was 73.
- D
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Inspectors wroteBased on interview and record review, the facility failed to ensure all resident funds were disbursed within 30 days of death. This affected one of one resident (#100) of one resident reviewed for disbursement of funds upon death. The facility identified nine residents with personal fund accounts residing in the facility. The facility census was 73.
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observations, record review, and interview, the facility failed to ensure residents' personal information was maintained in a manner to respect privacy related to personal and medical information. This affected two residents (#32 and #61) of 28 residents reviewed for privacy. The facility census was 73.
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on medical record review, interview and review of drug information from Medscape, the facility failed to ensure a resident had indications for use of an antipsychotic medication. This affected one (Resident #13) of three residents reviewed for psychotropic medication use.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on medical record review and interview, the facility failed to ensure required notifications were provided to residents and/or representatives upon transfer to the hospital for two (Residents #37 and #88) of two residents reviewed for hospitalization, and failed to provide a discharge summary for one (Resident #90) of two residents reviewed for discharge. The facility census was 73.
- D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on closed medical record review and interview, the facility failed to ensure timeliness of completion and submission of Minimum Data Set (MDS) assessments. This affected one (Resident #18) of two residents reviewed for submission of MDS assessments. The census was 73.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on medical record review and interview, the facility failed to ensure accuracy of Minimum Data Set (MDS) assessments. This affected two (Residents #10 and #32) of 27 residents whose assessments were reviewed for accuracy. The census was 73.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, medical record review and interview, the facility failed to ensure comprehensive care plans were developed for two (Residents #32, and #56) of 27 residents reviewed for comprehensive care planning. The census was 73.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on interview and record review, the facility failed to ensure three residents (Resident #57, #64 and #84) of 30 residents reviewed were offered to participate in care plan meetings. The facility census was 73.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observation, record review and interview, the facility failed to implement a restorative nursing program as recommended for Resident #3 following the resident's discharge from therapy to assist the resident to maintain her functional ability. This affected one resident (#3) of eight residents reviewed for activities of daily living.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interviews, record review, observation and review of the facility policy, the facility failed to ensure Hospice documentation was in place for Resident #34 to ensure collaboration between the facility and Hospice services. This affected one Resident, Resident #34 of one resident reviewed for Hospice services. The facility also failed to ensure Resident #32 had routine assessments of a non-pressure skin impairment and failed to ensure Resident #56 had continued monitoring of a skin rash. This affected two residents (Resident #32 and #56) of two residents reviewed for non-pressure wounds of the skin. The facility census was 73.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on medical record review, review of wound consultant notes, policy review, and interview, the facility failed to ensure routine skin assessments were completed for a resident with pressure ulcers. This affected one (Resident #32) of three residents reviewed for pressure ulcers The facility identified three residents with 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, interview, record review and review of the facility policy, the facility failed to ensure a comprehensive, resident centered fall prevention program was implemented to prevent resident falls and to ensure staff have access to resident information. This affected one resident, Resident #57 of one resident reviewed for falls with serious injury. The facility census was 73.
- 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 medical record review, observation, interview and policy review the facility failed to ensure Resident #30's urinary tract infection (UTI) was addressed timely and Resident #45 received timely incontinence care. This affected two residents (Resident #30 and #45) of two residents reviewed for bladder incontinence/urinary tract infection (UTI). The facility census was 73. Findings Include: 1. Review of the medical record for Resident #30 revealed an admission date of 08/09/17. Diagnoses included cognitive impairment, muscle weakness, chronic pain and anxiety. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had impaired cognition. Resident #30 was dependent on all activities of daily living (ADL's) and was incontinent of bowel and bladder. [...]
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review and physician and staff interviews, the facility failed to ensure medication was not received in an excessive dose for a resident. This affected one (Resident #88) of six residents reviewed for unnecessary medications. The facility census was 73.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview, record review, and review of the manufacturer instructions, the facility failed to ensure a medication error rate of less than five percent (%). Two errors were observed in 25 opportunities resulting in an 8.0% error rate. This affected one (Resident #83) of four residents observed for medication administration. The facility census was 73.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, interview, record review and review of the manufacturer instructions, the facility failed to prime an insulin pen per manufacturer instructions prior to administration, resulting in a significant medication error. This affected one (Resident #83) of one resident observed for insulin administration. The facility identified there were six residents who receive insulin. The facility census was 73.
- D
Provide routine and 24-hour emergency dental care for each resident.
Inspectors wroteBased on resident and staff interviews, observation and record review, the facility failed to ensure a resident was offered to see a dentist. This affected one (Resident #1) of three residents reviewed for dental services. The facility census was 73.
- D
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observation, resident and staff interviews, record review and policy review, the facility failed to honor food preferences of the residents. This affected one (Resident #84) of three residents reviewed for meal preferences. The facility census was 73.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on staff interviews and record review, the facility failed to ensure medical records were accurate. This affected one (Resident #45) of 30 residents reviewed for accurate medical records. The facility census was 73.
- C
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on staff interviews, personnel file review and policy review, the facility failed to ensure annual performance evaluations were completed for all certified nursing assistants (CNAs). This affected four of four personnel files reviewed for annual performance evaluations. This has the potential to affect all 73 residents residing in the facility.
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation and interview, the facility failed to ensure nursing staff information was posted in a prominent readily accessible location for residents, visitors, and staff. This had the potential to affect all 73 residents residing in the facility.
- C
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Inspectors wroteBased on review of the Facility Assessment and interview, the facility failed to update the facility assessment upon change in ownership to ensure it accurately reflected changes which were incorporated or in the process of being incorporated. This had the potential to affect all 73 residents.
April 4, 2024Standard inspection · 5 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, interview and policy review, the facility failed to provide a dignified dining experience for Resident #68. This affected one resident (#68) of one reviewed for dignity. The facility census was 78.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on record review and interview, the facility failed to provide Residents #72 and #73 with the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) informing them of the financial liability for continuation of skilled services not covered by Medicare. This affected two residents (#72 and #73) of three residents reviewed for beneficiary notification. The facility census was 78.
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on medical record review, interview, and policy review, the facility failed to ensure psychotropic medications which were ordered on an as necessary basis had a specific duration for use. This affected two (Resident #26 and #335) of six residents reviewed for the medical necessity of medication use. The facility census was 78.
- D
Implement a program that monitors antibiotic use.
Inspectors wroteBased on record review, interview and policy review, the facility failed to monitor prophylactic antibiotic use. This affected one resident (#23) of two residents reviewed for antibiotic use and one resident (#36) of five residents reviewed for unnecessary medications. The facility census was 78.
- B
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on record review and staff interview, the facility failed to ensure the ombudsman was notified, in writing, of the resident's transfer/discharge. This affected three residents of three residents (#2, #79 and #80) reviewed for hospitalization and discharge. The facility identified 52 residents transferred/discharged since January 2024. The facility census was 78.
June 8, 2023Standard inspection · 3 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review, interview and policy review, the facility failed to timely report allegations of abuse as required to the State Agency. This affected one resident (Resident #3) of one resident reviewed for abuse. The facility census was 81 residents.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and interview, the facility failed to ensure assessments were accurately completed. This affected two (Residents #44 and #75) of 21 residents reviewed for Minimum Data Set (MDS) 3.0 assessments. The facility census was 81.
- C
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on record review, facility policy, and interview, the facility failed to effectively implement their abuse policy and procedure to ensure all employees/potential employees were properly screened to ensure no employee had a finding or concern related to abuse, neglect or misappropriation. Two Licensed Practical Nurses (LPN) employees whose personnel files were reviewed contained no evidence the employees were checked against the State of Ohio Nurse Aide Registry (NAR) to identify if the employee had a finding concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property, upon hire. This had the potential to affect all 81 residents residing in the facility. Findings Include: Review of the personnel file for LPN #548 revealed a hire date of 02/16/23. The file contained no evidence the LPN was checked through the NAR upon hire. [...]
Fire safety inspections
36 fire safety citations on file: 15 on March 24, 2026, 8 on April 4, 2024, 13 on June 8, 2023.
Every fire safety citation36 citations
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · March 24, 2026 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · March 24, 2026 · Corrected (the home has a date of correction)
- F
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · March 24, 2026 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · March 24, 2026 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 24, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 24, 2026 · Corrected (the home has a date of correction)
- F
Meet other general requirements that are deficient.
K 500 · March 24, 2026 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · March 24, 2026 · Corrected (the home has a date of correction)
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · March 24, 2026 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · March 24, 2026 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · March 24, 2026 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · March 24, 2026 · Corrected (the home has a date of correction)
- E
Have a battery powered remote alarm panel in a location accessible by operating personnel.
K 916 · March 24, 2026 · deficient, provider has
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 24, 2026 · deficient, provider has
- E
Ensure proper usage of power strips and extension cords.
K 920 · March 24, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 4, 2024 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · April 4, 2024 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · April 4, 2024 · Corrected (the home has a date of correction)
- E
Have an enclosure around a vertical opening shaft.
K 311 · April 4, 2024 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · April 4, 2024 · Corrected (the home has a date of correction)
- E
Meet other general requirements that are deficient.
K 500 · April 4, 2024 · Corrected (the home has a date of correction)
- E
Have a battery powered remote alarm panel in a location accessible by operating personnel.
K 916 · April 4, 2024 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · April 4, 2024 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · June 8, 2023 · Corrected (the home has a date of correction)
- F
Have properly sized and located compartments to protect residents from smoke.
K 371 · June 8, 2023 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · June 8, 2023 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · June 8, 2023 · Corrected (the home has a date of correction)
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · June 8, 2023 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · June 8, 2023 · Corrected (the home has a date of correction)
- E
Meet other general requirements that are deficient.
K 300 · June 8, 2023 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · June 8, 2023 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · June 8, 2023 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 8, 2023 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · June 8, 2023 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · June 8, 2023 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · June 8, 2023 · Corrected (the home has a date of correction)