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 34 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
27D
2E
2F
Potential for minimal harm
0A
0B
2C
July 24, 2025Standard inspection · 2 citations
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure personal protective equipment (PPE) was worn for Enhanced Barrier Precaution (EBP) during medication administration via percutaneous endoscopic gastrostomy (PEG) tube for Resident #83. This affected one (Resident #83) five residents reviewed for medication administration had the potential to affect all residents on Registered Nurse (RN) #509's assignment, who had EBP's to include (Residents #3, #12, #35, and #36). The facility failed to ensure infection control was maintained during perineal care for Resident #94. [...]
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and staff interview, the facility failed to accurately code the preadmission screen and resident review (PASRR) status on the Minimum Data Set (MDS) 3.0 assessment for Residents #43 and #82. This affected two (Residents #43 and #82) of three residents identified by the facility as having a level two mental illness and/or an intellectual disability. The facility census was 80.
November 12, 2024Complaint inspection · 1 citation
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on interview, review of a self-reported incident (SRI), record review and review of the facility policies, the facility failed to ensure residents were free from unauthorized video recordings by staff. This affected one resident (#4) of three residents reviewed for abuse. The facility census was 88.
July 9, 2024Complaint inspection · 6 citations
- G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #6 and Resident #50 were free from resident to resident sexual abuse. This affected two residents (#6 and #50) of three residents reviewed for abuse. Actual physical and/or psychosocial harm, applying the reasonable person concept, occurred on 06/05/24 to Resident #50, a resident with impaired cognition, when Resident #101 who had a history of sexually inappropriate behaviors without care planned interventions in place, placed his hand down Resident #50's incontinence brief (an incident of sexual abuse). Following the incident, Resident #6 was visibly crying and shaking with a noted change by family on 06/06/24.
- 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 record review and interviews, the facility failed to report a change in condition to Resident #50's responsible party and physician, when the resident was sexually abused and was agitated and crying. This affected one resident (Resident #50) of three residents reviewed for notification of change in condition.
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on record review and interview, the facility failed to implement there abuse prohibition policy after an allegation of abuse was made to protect the residents, thoroughly investigation the allegation, and report the allegations and findings to the State agency. This finding affected two residents (Residents #6 and Resident #50) of three residents reviewed for abuse.
- 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 sexual abuse to the Administrator and State agency. This finding affected two residents (Residents #6 and Resident #50) of three residents reviewed for abuse.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review, interview, and policy review, the facility failed to thoroughly investigate allegations of resident to resident sexual abuse for Resident #6 and Resident #50. This affected two residents (Resident 6 and Resident #50) of three residents reviewed for abuse.
- 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 record review and interview, the facility failed to develop and implement comprehensive care plans for Resident #100's Intravenous (IV) medication. This affected one residents (Resident #100) out of three residents reviewed for care plans.
December 22, 2022Standard inspection · 10 citations
- 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 observation, interview and record review, the facility failed to report a change in condition to Resident #275's responsible party and physician, who had bruising to the left side of her neck. This affected one resident (Resident #275) of two residents reviewed for notification of change in condition.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on observation, interview and record review, the facility failed to timely report and investigate an injury of unknown origin for Resident #275. This affected one resident (Resident #275) of two residents reviewed for injuries of unknown origin.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and interview, the facility failed to maintain accurate Minimum Data Set (MDS) assessments for Resident #30 and Resident #66. This affected two residents (Resident #30 and Resident #60) of seven residents reviewed for accuracy of assessments.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on observation, interview and record review, the facility failed to complete a comprehensive baseline care plan for Resident #275 to include care for bruising and anticoagulant therapy. This affected one resident (Resident #275) of three residents reviewed for baseline care plans.
- 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 record review and interview, the facility failed to develop and implement comprehensive care plans for Resident #67's pain and Resident #66's pain and infection. This affected one resident (Resident #66) of three residents reviewed for infections and two residents (Resident #66 and #67) of five reviewed for pain.
- 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 observation, interview and record review, the facility failed to update the care plan for Resident #274 to include her missing eye glasses. This affected one resident (Resident #274) of five residents reviewed for comprehensive care plans.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview and record review, the facility failed to monitor Resident #275's change in condition related to bruising. This affected one resident (Resident #275) of three residents reviewed for quality of care.
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on observation, interview and record review, the facility failed to assist Resident #274 in replacing lost eye glasses to help maintain vision. This affected one resident (Resident #274) of one resident reviewed for vision.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident #42's chronic pain was addressed in a timely manner. This affected one resident (Resident #42) of five residents reviewed for medications.
- 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, interview and record review, the facility failed to properly store and secure medications for Resident #30 and Resident #67. This affected two residents (Resident #30 and #67) of two residents reviewed for medication storage.
October 3, 2019Standard inspection · 15 citations
- F
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on record review or interview, the facility failed to ensure the Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property policy reflected all staff were to be checked against the Ohio Nurse Aide Registry as required in the current regulatory language. This finding had the potential to affect all residents residing in the facility. The facility census was 86.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview and policy review, the facility failed to maintain a clean and sanitary kitchen. This affected all residents who take food by mouth. The facility identified two residents (Resident's #52 and #80) that did not receive food by mouth. The facility census was 86.
- E
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, interview and record review, the facility failed to develop individualized care plans for Resident's #30, #34, #59, #66, #76 and #80. This affected six residents of 41 Residents (#3, #5, #6, #7, #8, #9, #10, #12, #13, #15, #17, #19, #23, #24, #26, #27, #29, #30, #34, #38, #49, #51, #54, #55, #56, #57, #59, #63, #64, #65, #66, #75, #76, #78, #79, #80, #82, #83, #84, #282 and #283) records reviewed for individualized plans of care. The facility census was 86.
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure privacy was provided for during medication administration. This affected one (Resident #80) of four residents (Resident #34, #36, #80 and #86) observed for medication administration. The facility census was 86.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure Resident #54 was monitored for a reddened rash under the resident's bilateral breasts and failed to ensure coordination of Resident #76's code status. This finding affected one (Resident #54) of two residents reviewed for general skin conditions and one (Resident #76) of three residents reviewed for hospice. The facility census was 86.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure impaired skin areas were identified, assessed and treatments were put in place as ordered for Residents #29 and 30. This affected two of three residents (Resident #29, #30 and #34) reviewed for pressure ulcers. The facility census was 86.
- D
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.
Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to ensure medications were administered properly through a naso-gastric tube. This affected Resident #80, one of four residents (Residents #34, #36, #80 and #86) observed for medication administration, with a facility census of 86.
- 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 did not ensure the physician acted upon pharmacist recommendation timely for Residents #29 and #80. This affected two of six Residents (#17, #29, #49, #56, #66 and #80) reviewed for unnecessary medications. The facility census was 86.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were held as ordered based vital sign parameters for Resident #66. This affected one of six residents (Resident #17, #29, #49, #56, #66 and #80) reviewed for unnecessary medications. The facility census was 86.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the medication error rate was less than 5%. The error rate was 10.7% with three errors in 28 opportunities, affecting Residents #34 and #80. This affected two of four residents (Residents #34, #36, #80 and #86) observed for medication administration, with a facility census of 86.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate assessment in the record of Resident #66 regarding a transfer to the hospital. This affected one of three residents (Residents #27, #66 and #84) reviewed for hospitalization. The facility census was 86.
- D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure Residents #65 and #79's room and bedding was clean and sanitary. This finding affected two (Residents #65 and #79) of twenty-seven residents residing on the 100 hall.
- D
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observation, record review and interview, the facility did not ensure three residents were free from flying pests. This finding affected three (Residents #33, #65 and #79) of twenty-seven residents residing on the 100 hall.
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the nurse staffing information accurately reflected the correct date and staffing ratios. This finding had the potential to affect all 86 residents residing in the facility.
- C
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation, interview and policy review, the facility failed to ensure garbage was disposed of/stored in sanitary conditions to prevent the harborage of pests. This had the potential to affect all 86 residents in the facility.
Fire safety inspections
16 fire safety citations on file: 5 on July 24, 2025, 1 on December 22, 2022, 10 on October 3, 2019.
Every fire safety citation16 citations
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · July 24, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · July 24, 2025 · 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 · July 24, 2025 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · July 24, 2025 · Corrected (the home has a date of correction)
- E
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · July 24, 2025 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · December 22, 2022 · Corrected (the home has a date of correction)
- F
Install corridor and hallway doors that block smoke.
K 363 · October 3, 2019 · Corrected (the home has a date of correction)
- F
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · October 3, 2019 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · October 3, 2019 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · October 3, 2019 · 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 · October 3, 2019 · Corrected (the home has a date of correction)
- E
Provide a written emergency evacuation plan.
K 711 · October 3, 2019 · 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 · October 3, 2019 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · October 3, 2019 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · October 3, 2019 · Corrected (the home has a date of correction)
- C
Have simulated fire drills held at unexpected times.
K 712 · October 3, 2019 · Corrected (the home has a date of correction)