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 29 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
20D
7E
0F
Potential for minimal harm
0A
1B
1C
March 19, 2026Standard inspection · 2 citations
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of the medication error log, review of the incident report, staff and resident interview, and policy review, the facility failed to ensure residents were free from significant medication errors. This affected one (Resident #25) out of 22 sampled residents. The facility census was 70. Findings Include: Review of the medical record for Resident #25 revealed an admission date of 10/03/25 with diagnosis including chronic obstructive pulmonary disease, type two diabetes, and chronic pain. Review of the Minimum Data Set (MDS) assessment for Resident #25 dated 01/22/26 revealed the resident had moderate intact cognition. Resident was also assessed to be dependent on staff for activities of daily living (ADLs). [...]
- 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 medical record review, observation, staff interview, review of the facility document Stability of Common Insulins in Vials and Pens, and policy review, the facility failed to ensure the safe storage of insulin. This affected two (Resident #07 and #19 ) out of 17 residents with insulin orders. In addition, the facility failed to ensure ophthalmic medication was labeled with an open date. This affected one (Resident #39) out of 12 residents with ophthalmic orders. The facility census was 70. Findings Include:1. Review of the medical record for Resident #07 revealed an admission date of 01/20/26. Diagnoses included bipolar disorder, diabetes mellitus, and schizophrenia. Review of the minimum data set (MDS) assessment dated [DATE] revealed Resident #07 had severe cognitive impairment and was dependent on staff for activities of daily living (ADL). [...]
August 13, 2024Complaint inspection · 1 citation
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, medical record review, staff interview, and facility policy review, the facility failed to administered medications to residents as ordered. The medication administration observation identified four medication errors out of 39 medications administered for a medication error rate of 10.26 percent. This affected three (#19, #26, and #27) of four residents reviewed for medication administration. The facility census was 70.
May 15, 2024Complaint inspection · 2 citations
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, medical record review, staff interview, and policy review, the facility failed to ensure dependent residents were assisted with repositioning to prevent skin impairment. This affected three (#46, #53, #72) of three residents reviewed for repositioning. The census was 74.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, medical record review, staff interview, the facility failed to complete an accurate skin assessment. This affected one (#72) of three residents reviewed for skin assessments. The census was 74.
April 18, 2024Standard inspection · 11 citations
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure foods were stored in a manner to protect against the potential spread of food-borne illness. This had the potential to affect all 59 residents who received food from the kitchen. The facility identified 13 residents who were NPO (nothing by mouth) and did not receive food from the kitchen. The facility census was 72.
- 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 medical record review, staff interview, and policy review, the facility failed to ensure the physician was notified of a change in condition. This affected one (#22) of five residents reviewed for nutrition. The facility census was 72.
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on medical record review, review of the Resident Assessment Instrument (RAI) User Manual, review of the facility's Minimum Data Set (MDS) Completion and Submission Timeframe's policy and procedure, and staff interview, the facility failed to ensure MDS discharge assessment was completed within 14 days of discharge. This affected one (#60) of one resident reviewed for MDS discharge assessments. The facility census was 72.
- D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on medical record review, review of the Resident Assessment Instrument (RAI) User Manual, review of the facility's Minimum Data Set (MDS) Completion and Submission Timeframe's policy and procedure, and staff interviews, the facility failed to ensure MDS assessments were transmitted within 14 days of completion date. This affected three (#25, # 50, and #59) of three residents reviewed for MDS assessment submissions. The facility census was 72.
- D
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Inspectors wroteBased on medical record review and staff interviews, the facility failed to notify the state mental health authority of a significant change in condition for residents with mental disorders. This affected two (#9 and #49) of five residents reviewed for Pre-admission Screening and Resident Review, (PASARR) admission process. The total facility census was 72.
- 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, staff interview, medical record review,and policy review, the facility failed to ensure the plan of care reflected the fluid restriction as ordered by the physician. The affected one (#61) of one resident reviewed for fluid restriction. The total facility census was 72.
- D
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.
Inspectors wroteBased on observations, medical record review, resident interview, and staff interview, the facility failed to ensure physician orders were followed for assistive devices to prevent further contracture. This affected one (#52) of two residents reviewed for limited range of motion. The facility census was 72.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on medical record review, staff interview, review of the Resident Assessment Instrument (RAI), and policy review, the facility failed to ensure a resident's significant weight loss was addressed in an accurate and timely manner. This affected one (#42) of three residents reviewed for weight loss. The facility also failed to ensure weights were completed per the physician's order. This affected two (#09 and #22) of five residents reviewed for nutrition. The facility census was 72.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure the oxygen tubing was changed and dated as ordered by the physician. This affected for two (#19 and #61) of two residents reviewed for oxygen administration orders. The total facility census was 72.
- D
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Inspectors wroteBased on observation and staff interview, the facility failed to provide full visual privacy for resident. This affected for two (#48 and #61) of three residents reviewed for physical environment. The total facility census was 72.
- C
Post nurse staffing information every day.
Inspectors wroteBased on record review and staff interview, the facility failed to post nurse staffing information that included the total number worked daily of Registered Nurses, Licensed Practical Nurses, and State Tested Nurse Aides. This had the potential to affect all 72 residents in the building. The census was 72.
December 1, 2023Complaint inspection · 3 citations
- E
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on staff interview, medical record review, and review of pharmacy board website, the facility failed to administer parenteral fluids per professional standards when they allowed a company who was not licensed in Ohio by the State Pharmacy Board to administer dangerous intravenous (IV) fluid medications to residents. This affected three (Resident #46, #48 and #65) of three reviewed for pharmacy services. The facility identified 13 former residents, (Residents #70,#71,#72,#73,#74,#75,#76,#77,#78,#79,#80,#81 and #82) and 32 residents who currently reside in the facility, (Residents #65,#2,#3,#5,#7,#10,#11,#48,#12,#15,#17,#18,#19,#21,#23,#26,#46, #28,#30,#31,#33,#38,#41,#42,#45,#51,#55,#57,#60,#62,#63,and #64) who received intravenous fluids through the unlicensed company. The facility census was 65.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on staff interview, medical record review, and review of pharmacy board website, the facility failed to provide pharmaceuticals services that assure the accurate acquiring, receiving, and dispensing of drugs when they allowed a company who was not licensed in Ohio by the State Pharmacy Board to administer dangerous intravenous (IV) fluid medications. This affected three (Resident #46, #48 and #65) of three reviewed for pharmacy services. The facility identified 13 former residents, (Residents #70,#71,#72,#73,#74,#75,#76,#77,#78,#79,#80,#81 and #82) and 32 residents who currently reside in the facility, (Residents #65,#2,#3,#5,#7,#10,#11,#48,#12,#46,#15,#17,#18,#19,#21,#23,#26,#28,#30,#31,#33,#38,#41,#42,#45,#51,#55,#57,#60,#62,#63,and #64) who received intravenous fluids through the unlicensed company. The facility census was 65.
- E
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Inspectors wroteBased on staff interview, medical record review, and pharmacy board website review, the facility failed to ensure an outside Intravenous (IV) company (IV Company #700) had a proper license to provide services to residents. This affected three (Resident #46, #48 and #65) of three reviewed for pharmacy services. The facility identified 13 former residents, (Residents #70,#71,#72,#73,#74,#75,#76,#77,#78,#79,#80,#81 and #82) and 32 residents who currently reside in the facility, (Residents #65,#2,#3,#5,#7,#10,#11,#48,#46, #12,#15,#17,#18,#19,#21,#23,#26,#28,#30,#31,#33,#38,#41,#42,#45,#51,#55,#57,#60,#62,#63,and #64) who received intravenous fluids through the unlicensed company. The facility census was 65.
June 28, 2023Standard inspection · 10 citations
- E
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 record review, observation, policy review, and staff interview, the facility failed to prepare puree foods as planned in the facility's spreadsheet and recipes. This had the potential to affect all nine residents (Residents #1, #7, #9, #20, #23, #26, #27, #56, and #59) receiving pureed food from the kitchen. The facility census was 72.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on policy review, observations, and staff interview, the facility failed to store foods, discard expired foods and maintain food equipment in good repair. This had the potential to affect 63 residents who received food from the kitchen. The facility census was 72.
- E
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Inspectors wroteBased on observations and staff interviews, the facility failed to provide a full visual privacy of each resident. This affected six (Residents #7, #40, #50, #65, #68, and #226) of 56 residents residing in double occupancy rooms. The facility census was 72.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, record review, and staff interview, the facility failed to treat residents with respect and dignity when they posted care information on the door of a resident's room. This affected one (Resident #22) of two residents reviewed for respect and dignity. The facility census was 72.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on resident and staff interviews, policy review, observations, and record review, the facility failed to provide reasonable accommodation of a call light that adapted to the needs of the resident. This affected one (Resident #50) of three residents reviewed for accommodation of needs. The facility census was 72.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on medical record review, resident and staff interview, review of the facility's Self-Reported Incidents (SRIs), and policy review, the facility failed to timely report an allegation of misappropriation of a resident's credit card to administration and the State Survey Agency. This affected one (Resident #49) of one resident reviewed for abuse and misappropriation. The facility census was 72.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on resident and staff interview and record review, the facility failed to ensure a resident who required assistance from staff with activities of daily received bathing as scheduled. This affected one (Resident #32) of three residents reviewed for activities of daily living. The facility identified all 72 residents required assistance from staff with bathing. The facility census was 72.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on staff interview and record review, the facility failed to have ensure the resident's pressure ulcers were documented accurately upon re-admission to the facility. This affected one (#28) of four residents reviewed for pressure ulcers. The facility census was 72.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on record review, observation, policy review, and staff interview, the facility failed to complete hand hygiene after removing gloves during a resident's wound treatment. This affected one (Resident #58) of three residents reviewed for infections. The facility census was 72.
- B
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on medical record review, staff interview, and review of the resident assessment instrument (RAI) manual, the facility failed to ensure the residents' completed Minimum Data Set (MDS) assessments were submitted to the Centers for Medicare and Medicaid Service's (CMS) system within 14 days after completion of the assessment. This affected four (#4, #40, #42, and #51) of 18 residents reviewed for MDS assessments. The facility census was 72.
Fire safety inspections
32 fire safety citations on file: 7 on March 19, 2026, 9 on April 18, 2024, 16 on June 28, 2023.
Every fire safety citation32 citations
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · March 19, 2026 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 19, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 19, 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 19, 2026 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · March 19, 2026 · 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 · March 19, 2026 · Corrected (the home has a date of correction)
- E
Have proper power supply for life support equipment.
K 915 · March 19, 2026 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 18, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 18, 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 18, 2024 · Corrected (the home has a date of correction)
- E
Use approved construction type or materials.
K 161 · April 18, 2024 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · April 18, 2024 · Corrected (the home has a date of correction)
- E
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · April 18, 2024 · 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 · April 18, 2024 · Corrected (the home has a date of correction)
- E
Have proper power supply for life support equipment.
K 915 · April 18, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · April 18, 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 28, 2023 · Corrected (the home has a date of correction)
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · June 28, 2023 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · June 28, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 28, 2023 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · June 28, 2023 · Corrected (the home has a date of correction)
- F
Have a battery powered remote alarm panel in a location accessible by operating personnel.
K 916 · June 28, 2023 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · June 28, 2023 · Corrected (the home has a date of correction)
- E
Meet requirements for sections of health care facilities separated by fire resistive construction.
K 131 · June 28, 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 28, 2023 · Corrected (the home has a date of correction)
- E
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · June 28, 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 28, 2023 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · June 28, 2023 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · June 28, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · June 28, 2023 · Corrected (the home has a date of correction)
- E
Have proper power supply for life support equipment.
K 915 · June 28, 2023 · Waiver
- E
Ensure proper usage of power strips and extension cords.
K 920 · June 28, 2023 · Corrected (the home has a date of correction)