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 42 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
21D
8E
10F
Potential for minimal harm
0A
0B
2C
January 15, 2026Standard inspection, Complaint inspection · 4 citations
- E
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 and interviews, the facility failed to maintain resident rooms in a safe and sanitary condition. This affected 14 residents (#1, #3, #36, #39, #52, #60, #63, #64, #65, #72, #84, #94, #100 and #101) out of 24 residents reviewed for environment. The facility census was 103.
- 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 observation, record review and interview the facility failed to provide restorative services to prevent a decline of the residents' functional abilities in the facility. This affected three residents (#10, #14 and #54) out of four residents reviewed for rehabilitation services. The facility census was 103.
- 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 ensure there was accurate documentation. This affected two residents (#31 and #42) out of 24 medical records reviewed for accuracy of medical records. The facility census was 103.
- C
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Inspectors wroteBased on observation and interview, the facility failed to post the most recent survey results readily accessible to residents and family members. This had the potential to affect all 103 residents residing in the facility.
January 23, 2025Complaint inspection · 1 citation
- F
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on observation, review of the facility's contract with therapy services, resident interview, and staff interview, the facility failed to administer the facility in a manner to maintain therapy equipment in proper working order. This affected one resident (#51) and had the potential to affect all 91 residents in the facility.
August 21, 2024Complaint inspection · 2 citations
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview, record review, facility investigation review, and facility policy review the facility failed to ensure Resident #73 was transferred safely resulting in a fall. This affected one resident (#73) of three residents reviewed for accidents. Facility census was 83.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation and interview, the facility failed to ensure medications were administered with an error rate of less than 5%. A total of two errors out of 29 opportunities observed resulting in a 6.9% medication error rate. This affected two resident (#36 and #73) out of four observed for medication administration.
July 19, 2024Complaint inspection · 1 citation
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observations, resident interview, staff interview, and facility policy review, the facility failed to ensure food served was palatable for all residents. This affected four residents (#45, #47, #50, and #62) of five residents observed for food palatability and had the potential to affect all residents receiving food from the facility. The facility census was 90.
May 8, 2024Standard 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 observation, interview and facility policy review, the facility failed to ensure food items were appropriately labeled, dated and contained. This had the potential to affect 85 residents receiving meals from the kitchen as three residents (#41, #71 and #77) were ordered nothing-by-mouth (NPO). The facility census was 88.
- D
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Inspectors wroteBased on interview, record review and facility policy review, the facility failed to provide spend-down letters for each month residents were approaching or over the resource limit. This affected two residents (#11 and #16) of five residents reviewed for resident funds. The facility census was 88.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and staff interview, the facility failed to accurately code comprehensive assessments for two residents (#54 and #88) of 24 residents reviewed for assessments. The facility census was 88. Findings Include: 1. Medical record review revealed Resident #88 was admitted to the facility on [DATE] with diagnoses including surgical aftercare following skin grafts to bilateral feet for burns, diabetes, stroke, end stage renal disease dependent on dialysis, and high blood pressure. Review of the physician's orders dated 02/13/24 revealed an order for oxycodone (an opioid pain medication) 5 milligrams (mg) orally every six hours as needed for pain. [...]
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview, medical record review, and policy review, the facility failed to ensure a medication error rate of less than five percent (%). Six medication errors occurred within 31 observed opportunities for error resulting in an error rate of 19.35% . This affected three residents (Residents # 241, #41, and #58) of nine residents observed during medication administration. The facility census was 88.
October 23, 2023Complaint inspection · 4 citations
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed medical record review, review of Emergency Department notes, review of facility investigative information, review of facility elopement and missing resident policy and procedures and interviews, the facility failed to provide adequate supervision to prevent Resident #92, who had cognitive impairment, wandering behaviors and diagnoses of schizophrenia and dementia, from eloping from the facility. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm on 08/18/23 at approximately 8:30 P.M. when Resident #92 walked through the secured third-floor nursing unit back hallway door leading to a stairwell without staff knowledge; [...]
- F
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on staff interview, review of personnel files and review of the facility abuse prevention policy and procedure, the facility failed to implement policies and procedures to include screening of all employees against the State of Ohio Nurse Aide Registry to identify if an employee had a finding concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property This had the potential to affect all 91 residents residing in the facility.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, record review and review of the facility policy, the facility failed to ensure Resident's #15, #26, #49 and #50 were supervised while they were smoking and failed to ensure Resident #15 was wearing a smoking apron while smoking. This affected four residents (#15, #26, #49 and #50) reviewed for smoking safety and had the potential to affect all 33 residents (Resident's #1, #2, #5, #6, #8, #9, #11, #13, #14, #15, #18, #23, #25, #26, #33, #36, #43, #49, #50, #54, #56, #58, #59, #61, #62, #64, #67, #74, #75, #80, #87, #89, #95) who smoked in the facility. The facility census was 91.
- 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, interview, record review and review of facility policy the facility failed to ensure Resident #67's right knee skin impairment was accurately documented to include wound type in the medical record. This affected one resident (Resident #67) out of three residents reviewed for wounds. The facility census was 91.
March 17, 2022Standard inspection · 26 citations
- 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 the services of a Registered Nurse (RN) were maintained for at least eight hours a day, seven days a week. This had the potential to affect all 85 residents currently residing in the facility.
- 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 and interview the facility failed to ensure medications were secured, not expired and medications carts did not contain loose unidentifiable medications. This had the potential to affect all 85 residents currently residing in the facility.
- F
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Inspectors wroteBased on observation and interview the facility failed to employ a designated person to serve as director of food services who meets qualifications. This had the potential to affect 77 residents who received meals in the facility. The facility identified Residents #11, #12, #21, #40, #65, #67, #57, and #434 as receiving no food from the kitchen. The facility census was 85.
- F
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation and resident and staff interview the facility failed to ensure foods were served at a palatable temperature and were visually pleasing. This affected six (Residents #5, #39, #66, #74, #435 and #438) of six residents reviewed for food and had the potential to affect and additional 71 residents who received meals prepared by the kitchen. The facility identified Residents #11, #12, #21, #40, #65, #67, #57, and #434 as receiving no food from the kitchen. The facility census was 85.
- 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 record review the facility failed to maintain a clean and sanitary kitchen area. This had the potential to affect 77 residents who received meals in the facility. The facility identified Residents #11, #12, #21, #40, #65, #67, #57, and #434 as receiving no food from the kitchen. The facility census was 85.
- F
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation, interview and record review, the facility failed to properly dispose of garbage and refuse in the dumpster. This had the potential to affect all 85 residents currently residing in the facility.
- F
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 and staff interview the facility failed to ensure it maintained a clean and sanitary environment. This had the potential to affect all 85 residents currently residing in the facility.
- E
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 interview, medical record review, and facility policy review the facility failed to ensure residents' code status (level of medical interventions a resident wishes to have performed in the event they experienced an absence of a heartbeat or breathing) entered in the electronic medical record matched the State of Ohio Do Not Resuscitate (DNR) written documents for three residents (#31, #57, and #67) of nine residents reviewed for advanced directives. The facility census was 85.
- E
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and staff interview the facility failed to accurately code the pre-admission screening and resident review (PASRR) accurately on the Minimum Data Set (MDS) 3.0 assessment. This affected five (Residents #24, #52, #61, #64 and #76) of six residents reviewed for accuracy of PASRR coding of MDS assessments. The facility identified twelve residents as having a level two mental illness.
- 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 record review and staff interview the facility failed to develop resident specific care plans to address residents individual needs and to implement care planned interventions as required. This affected six (Residents #31, #35, #65, #66, #435 and #436) of 24 sampled residents. The facility census was 85. Findings Include: 1. Resident #66 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease, bi-polar disorder and schizophrenia. Review of the care plan initiated 02/01/22 revealed the care plan contained the following information. Resident has potential and desires to be discharged to No destination was noted. Resident is at risk for isolation. No cause of isolation risk was given. Resident is at risk for constipation. [...]
- E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview, medical record review, and policy review the facility failed to provide documentation that residents and/or their representatives were provided educational information regarding the risks and benefits, and informed consent/refusal for influenza and pneumococcal vaccinations. This affected five (Residents #12, #13, #67, #429, and #439) of seven residents reviewed for influenza and pneumococcal immunizations. The facility census was 85.
- E
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Inspectors wroteBased on interview, medical record review, and facility policy review, and review of the Centers for Medicare and Medicaid (CMS) guidance the facility failed to provide documentation that residents and/or their representatives were provided educational information including risks and benefits, and informed consent/refusal for COVID-19 vaccinations. This affected three (Residents #67, #429, and #439) of seven residents reviewed for COVID-19 immunizations. The facility census was 85.
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on record review and staff interview the facility failed to complete a Minimum Data Set (MDS) 3.0 assessment as required upon resident discharge to the hospital. This affected one (Resident #2) of one resident reviewed for MDS accuracy. The facility census was 85.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on record review and staff interview the facility failed to ensure the pre-admission screen and resident review (PASRR) was accurate and reflective of current mental healthcare needs. This affected one (Resident #66) of twelve residents reviewed for PASRR status. The facility census was 85.
- 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 medical record review the facility failed to develop a person-centered care plan for Resident #31. This affected one of six residents reviewed for care plan timing and revision. The facility census was 85. Review of the medical record for Resident #31 revealed an admission date of 08/22/19. Diagnoses included orthopedic care following surgical amputation, local infection of the skin and subcutaneous (under the skin) tissue, type 2 diabetes, chronic obstructive pulmonary disease (COPD), moderate protein calorie malnutrition, hemiplegia and hemiparesis following cerebral infarction, Methicillin-resistant staphylococcus aureus (MRSA) of unspecified site, idiopathic aseptic necrosis of left toes, acquired absence of right leg above knee, major depressive disorder, and chronic viral hepatitis C. [...]
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation and interview the facility failed to ensure routine turning and positioning for Resident #67 and adequate nail care for Residents #65 and #30. This affected three (Residents #67, #65 and #30) of six residents reviewed who were dependent for activities of daily living care. The facility census was 85.
- 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 heel pressure offloading devices (PODs) were appropriately applied and routine repositioning was completed to promote the healing of existing pressure ulcers for Resident #18 and failed to provide adequate wound care for Resident #66. This affected two (Resident #18 and #66) of four residents reviewed for pressure ulcers. The facility census was 85.
- D
Provide appropriate foot care.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure ancillary podiatry visits were provided and adequate foot care was administered to Resident #65. This affected one (Resident #65) of three residents reviewed for ancillary services. The facility census was 85.
- 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 observation and interview the facility failed to provide adequate care for the use of an indwelling urinary catheter. This affected one (Resident #67) of one resident observed for catheter care. The facility census was 85.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, record review, and review of facility policy the facility failed to ensure Resident #18 was assessed for nutritional needs and to implement new interventions to address a significant unplanned weight loss and failed to ensure the resident was provided feeding assistance with meals. This affected one of eight residents reviewed for nutritional status. The facility census was 85.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation and interview the facility failed to ensure medications were administered with an error rate of less than 5%. A total of 12 errors out of 27 opportunities observed resulted in a 44.4% medication error rate. This affected one resident (#40) of three (#41, #49 and #40) observed for medication administration. The facility census was 85.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were free of significant medication errors. This affected one (Resident #40) of three observed for medication administration.
- D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on observation, taste test and diet manual review the facility failed to prepare pureed foods at the proper consistency. This had the potential to affect two (Residents #280 and #432) of two residents prescribed a pureed diet. The facility census was 85.
- 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, observation, and medical record review the facility failed to ensure accurate documentation was contained in the medical record. This affected two (Residents #31 and #47) of six residents reviewed for accurate documentation. The facility census was 85.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and policy review the facility failed to follow appropriate infection control procedures during provision of incontinence care for Resident #31 and medication administration for Resident #40. This affected one (Residents #31) of three residents observed for personal care and one (Resident #40) of three residents observed for medication administration. The facility census was 85.
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation, record review and interview the facility failed to ensure posted staffing information was updated daily. This had the potential to affect all 85 residents.
Fire safety inspections
32 fire safety citations on file: 14 on January 15, 2026, 12 on May 8, 2024, 6 on March 17, 2022.
Every fire safety citation32 citations
- F
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 · January 15, 2026 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · January 15, 2026 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · January 15, 2026 · Corrected (the home has a date of correction)
- F
Install corridor and hallway doors that block smoke.
K 363 · January 15, 2026 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · January 15, 2026 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · January 15, 2026 · Corrected (the home has a date of correction)
- F
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · January 15, 2026 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · January 15, 2026 · Corrected (the home has a date of correction)
- E
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · January 15, 2026 · Corrected (the home has a date of correction)
- E
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
K 232 · January 15, 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 · January 15, 2026 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · January 15, 2026 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 15, 2026 · Corrected (the home has a date of correction)
- E
Install properly constructed and protected linen or trash chutes.
K 541 · January 15, 2026 · Corrected (the home has a date of correction)
- F
Use approved construction type or materials.
K 161 · May 8, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 8, 2024 · Corrected (the home has a date of correction)
- F
Install corridor and hallway doors that block smoke.
K 363 · May 8, 2024 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · May 8, 2024 · Corrected (the home has a date of correction)
- F
Have proper medical gas storage and administration areas.
K 923 · May 8, 2024 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · May 8, 2024 · 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 · May 8, 2024 · Corrected (the home has a date of correction)
- E
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · May 8, 2024 · fire safety evaluation s
- E
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
K 232 · May 8, 2024 · fire safety evaluation s
- 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 · May 8, 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 · May 8, 2024 · Corrected (the home has a date of correction)
- C
Address subsistence needs for staff and patients.
E 15 · May 8, 2024 · deficient, provider has
- E
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · March 17, 2022 · fire safety evaluation s
- E
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
K 232 · March 17, 2022 · fire safety evaluation s
- E
Have an enclosure around a vertical opening shaft.
K 311 · March 17, 2022 · Corrected (the home has a date of correction)
- E
Construct fire resistant interior walls.
K 331 · March 17, 2022 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · March 17, 2022 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · March 17, 2022 · Corrected (the home has a date of correction)