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 27 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
18D
5E
1F
Potential for minimal harm
0A
0B
2C
June 11, 2026Standard inspection, Complaint inspection · 4 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, interviews, and policy reviews the facility failed to ensure food was stored, prepared, and served under sanitary conditions. This had the potential to affect all residents consuming food prepared in the kitchen. No residents in the facility were nothing by mouth (NPO). The facility census was 104.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, staff interview, and policy review the facility failed to ensure residents were treated with respect and dignity when staff stood over residents as they fed them lunch. This affected two residents (#26 and #48) of twenty four reviewed for dining observation. The facility census was 104.
- 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, staff interview, record review, and policy review, the facility failed to ensure medications were locked in a medication cart. This had the potential to affect one resident (#84) of two residents who were independently mobile and cognitively impaired that resided on the100 hall. The facility census was 104.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interview, and review of Center for Disease Control and Prevention (CDC), the facility failed to adhere to infection control practices as suggested by the CDC when wound care supplies of calcium alginate were being stored on the floor in a plastic bag. This had the potential affect one resident (#5) of three reviewed for wound care. The facility census was 104.
April 7, 2026Complaint inspection · 5 citations
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on interview, record review and facility policy review, the facility failed to ensure a safe discharge. This affected one Resident #111 of three residents reviewed for discharge. The facility census was 104.
- 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, record review and policy review, the facility failed to have a baseline care plan that included pain management and hearing loss. This affected one, (Resident #2) of six residents reviewed for the baseline care plan. The facility census was 104.
- 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, interviews, policy review and record reviews, the facility failed to ensure residents' activity needs were assessed regularly and addressed in the care plans. This affected two Residents #40 and Resident #54 of three residents reviewed for care plans. The facility census was 104.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure pain medications were available for a resident. This affected one, (Resident #2) of six residents reviewed for medications. The facility census was 104.
- 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, interview and record review, the facility failed to ensure a sanitary environment. This affected one, (Resident #54) of three residents reviewed for a sanitary environment. The facility census was 104.
November 26, 2025Complaint inspection · 1 citation
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on staff interviews, interview with staff at oral surgeon's office, review of the weather history for Cincinnati, and record review, the facility failed to ensure residents were treated with respect and dignity. This affected one (#12) of two residents reviewed for dignity and respect. The facility census was 102.
December 10, 2024Complaint inspection · 1 citation
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on closed medical record review, staff interviews, interview with Wound Nurse Practitioner (WNP) #175, review of facility policy, and review of guidelines from the National Pressure Injury Advisory Panel (NPIAP), the facility failed to adequately assess and monitor residents' skin and failed to timely identify pressure ulcers (a pressure ulcer is a localized injury of the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). This resulted in Actual Harm when Resident #104 who was admitted without pressure ulcers but was at risk for the development of pressure ulcers, subsequently developed an avoidable facility acquired pressure ulcer which was not identified until it had reached an advanced stage. [...]
February 8, 2024Standard inspection, Complaint inspection · 5 citations
- E
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on medical record reviews, observations, resident interviews, staff interviews, and policy reviews, the facility failed to ensure resident call lights were in working order on the facility's 200-hall. This affected 12 residents (#12, #14, #19, #23, #32, #42, #54, #57, #59, #74, #91, and #94) of 27 residents reviewed for call lights. The facility census was 95.
- D
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on resident and staff interviews, review of resident council meeting notes, and record review, the facility failed to address resident concerns timely and ensure staff only attend the meetings if the residents invited them to attend. This affected three (#47, #78, and #88) of four residents who attended the resident council meeting. The facility census was 95.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record reviews, staff interviews, review of the facility's policy, and observations, the facility failed to ensure a resident's safety devices for the prevention of falls were functioning and failed to complete a thorough fall investigation into a resident's fall. This affected two (Residents #27 and #95) of seven residents reviewed for falls. The facility census was 95.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on medical record review, observation, staff interview, and policy review, the facility failed to ensure oxygen tubing was changed, labeled, and dated per the physician's order, plan of care, and facility policy and the facility failed to ensure oxygen was administered in a safe manner. This affected one (#49) of one resident reviewed for oxygen use. The facility identified 15 residents who used oxygen. The facility census was 95.
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation and staff interview, the facility failed to post daily staffing data at the beginning of each shift. This had the potential to affect all 95 residents who resided in the facility.
February 13, 2020Standard inspection · 11 citations
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on record review, observation, staff interview, and review of facility policy, the facility failed to appropriately document the number the shift to shift counting of controlled substances in the 100 Hall cart. This had the potential to affect 16 sixteen (#18, #36, #52, #53, #71, #73, #75, #138, #139, #140, #144, #149, #150, #151, #240, #290) residents with controlled substances stored in the 100 hall cart. Facility census was 93.
- E
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 facility policy, and review of manufacturer's recommendations the facility failed to discard expired medications and failed to date injectable medication upon opening to ensure it was discarded in a timely manner in accordance with manufacturer's recommendations. This had the potential to affect the six (#24, #71, #142, #288, #289, #290) residents. The census was 93.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, resident and staff interview and policy review, the facility failed to ensure meals were served in a safe and appetizing temperature. This had the potential to affect 33 residents residing on the 100 halls, except Resident #20 who does not receive dietary services. Facility census was 93.
- 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 store food properly and maintain a clean and sanitary kitchen to prepare food. This had the potential to affect 92 out of 93 residents residing in the facility, except one (#20) resident who did not receive food from the kitchen. Facility census was 93.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on record review, observation and resident and staff interview, the facility failed to accommodate a residents need by providing a resident with an alternate mobility device while her motorized wheelchair was being repaired. This affected one (#40) of 19 residents sampled during the survey. The census was 93.
- 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 medical record review, observation, resident representative and staff interview and policy review, the facility failed to ensure a resident was afforded with the choice of food preferences with each meal. This affected one (#11) of one reviewed for choices. The facility census was 93.
- 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 medical record review, staff interview, and review of facility policy, the facility failed to ensure resident code status was communicated consistently and accurately to the staff. This affected two (#24 and #18) of two residents reviewed for advanced directives. The census was 93.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and staff interview, the facility failed to ensure resident Minimum Data Set (MDS) assessments accurately reflected resident psychiatric diagnoses. This affected one (#18) of six residents reviewed for unnecessary medications. The census was 93.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on medical record review, observation, resident, resident representative and staff interview and policy review, the facility failed to provide dental care for dependent residents. This affected one (#11) of one resident reviewed for activities of daily living. The facility census was 93.
- 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, staff interview, and review of facility policy, the facility failed to ensure as needed anti-anxiety medication had a stop date and failed to thoroughly document target behaviors and non-pharmacological interventions offered prior to administration of an as needed anti-anxiety medication. This affected one (#18) of six residents reviewed for unnecessary medications. The census was 93.
- C
Ensure the activities program is directed by a qualified professional.
Inspectors wroteBased on personnel file review, staff interview and review of a job description, the facility failed to ensure a qualified Activity Director was on staff to oversee the facility's overall activity services. This had the potential to affect every resident residing in the facility. The census was 93.
Fire safety inspections
7 fire safety citations on file: 3 on June 11, 2026, 2 on February 8, 2024, 2 on February 13, 2020.
Every fire safety citation7 citations
- F
Install an approved automatic sprinkler system.
K 351 · June 11, 2026 · Not yet corrected
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · June 11, 2026 · Not yet corrected
- E
Have proper power supply for life support equipment.
K 915 · June 11, 2026 · Not yet corrected
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 8, 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 · February 8, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 13, 2020 · Waiver
- E
Have properly installed electrical wiring and gas equipment.
K 511 · February 13, 2020 · Corrected (the home has a date of correction)