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 26 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
2J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
16D
3E
4F
Potential for minimal harm
0A
0B
0C
May 6, 2026Complaint inspection · 3 citations
- J
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on closed record review, review of an Emergency Medical Service (EMS) report, review of the facility policy, review of National Institute of Health information, review of the Ohio Board of Nursing Standards of Practice and interview the facility failed to ensure Resident #91, who had advance directives for a Full Code status (life saving measures to be provided if necessary) was comprehensively assessed and provided timely monitoring after experiencing an acute change of condition to ensure prompt and necessary medical intervention was provided to the resident. Immediate Jeopardy with Actual Harm and subsequent death began on [DATE] at 10:05 A.M. when Resident #91 was noted to be pale, disoriented and confused; with changes to his eyes/vision and lung congestion. Resident #91 was assessed to be tachycardic with a pulse of 102 beats per minute. [...]
- G
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, record review, hospital record review and interview, the facility failed to ensure adequate monitoring and treatment of urinary complications related to an indwelling catheter. Actual harm occurred on 04/27/26 to Resident #35 after an indwelling catheter was removed due to reported pain and burning, the resident's urine output was not thoroughly monitored, and when the catheter was re inserted the resident continued to have significant pain with no output, resulting in hospitalization where an acute kidney injury and approximately 1000 milliliters (mL) of urinary retention was identified. This affected one resident (#35) of two residents reviewed for urinary catheters. The facility census was 89.
- 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 interview, record review, and review of the facility policy the facility failed to ensure facility staff notified Resident #90's responsible party of a change of condition. This affected one resident (Residents #90) out of three reviewed for notification. The facility census was 89.
January 20, 2026Complaint inspection · 5 citations
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on interview, record review, review of communication documentation, and facility policy review, the facility failed to ensure private information had not been shared with individuals that had not been authorized. This affected one resident (#78) of two reviewed for privacy. The facility census was 76.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure routine bathing care was provided to residents. This affected two residents (#23 and #31) of three residents reviewed for activities of daily living. The facility census was 76.
- 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 record review, interview, review of relevant personnel records, and facility policy review, the facility failed to ensure timely incontinence care was provided to residents. This affected two residents (#23 and #24) of three residents observed and reviewed for incontinence care. The facility census was 76.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on record review, interview, review of self reported incident (SRI) and corresponding investigation, and facility policy review, the facility failed to ensure pain was comprehensively assessed and pain medications was administered timely after resident complaint of severe pain. This affected one resident (#18) of three residents reviewed for pain management. The facility census was 76.
- 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, record review, and facility policy review, the facility failed to ensure medications were not left unattended in residents' rooms. This affected one resident (#19) of four residents observed for unattended medications. The facility census was 76.
September 16, 2025Complaint inspection · 2 citations
- F
Dispose of garbage and refuse properly.
Inspectors wroteBased on observations, interviews and policy review, the facility failed to maintain a sanitary area surrounding the garbage dumpsters. This had the potential for affect all residents residing in the facility. The facility census was 77.
- 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 observations, interviews, and policy review, the facility failed to maintain a sanitary homelike environment for residents. This had the potential to affect all residents residing in the facility. The facility census was 77.
June 14, 2024Complaint inspection · 6 citations
- J
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on closed medical record review, hospital record review, review of a police and Emergency Medical Service (EMS) report, social media review, review of the Food and Drug Administration online medication information, policy review and interviews, the facility failed to timely respond and take appropriate action (e.g., suspending administration of an anticoagulant) in regard to an elevated International Normalized Ratio (INR) for Resident #11, who was receiving Warfarin (Coumadin) for atrial fibrillation. This resulted in Immediate Jeopardy and the potential for serious harm on 05/20/24 when the resident's INR, per laboratory testing, was abnormally high at 4.9 and staff failed to notify the physician or stop the administration of the medication, Coumadin. [...]
- E
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on record review and interview, the facility failed to ensure resident care needs were adequately and timely met to decrease/prevent residents from contacting the local fire and police department for care including routine care and assistance. This affected eleven residents (#4, #11, #12, #13, #19, #42, #51, #54, #75, #79, and #98) of 83 residents who resided in the facility.
- E
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 record review and interview, the facility failed to ensure sufficient nursing staff with the appropriate competencies and skills sets were on duty and provided the necessary access to the resident's electronic health record to ensure medications were administered in a timely manner. This affected 15 residents (#5, #12, #29, #49, #53, #54, #55, #58, #59, #64, #67, #71, #72, #78 and #84's) assigned to Licensed Practical Nurse (LPN) #401 on 06/04/24. The facility census was 83.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review, interview and policy review the facility failed to ensure Resident #40's non-pressure skin treatments were administered as ordered. This affected one (Resident #40) of three residents reviewed for skin alterations.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on closed record review, hospital record review, policy review and interview, the facility failed to ensure Resident #11 was administered pain medications as ordered. This affected one (Resident #11) of four residents reviewed for medication administration.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a medication error rate of less than five percent (%). This affected one resident (Resident #33) of four residents reviewed for medication administration. A total of thirty medications were administered with two errors for a medication error rate of 6.66%.
March 25, 2024Standard inspection · 6 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, record review, and policy and procedure review, the facility failed to maintain a clean and sanitary kitchen and nursing unit areas, failed to ensure staff wore hairnets while in the kitchen, and failed to ensure scoops were not stored in the containers with the food items. This had the potential to affect all residents except three residents (#48, #66, and #69) who received nothing by mouth. The facility census was 88.
- 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 did not ensure the laundry room was maintained in a clean and sanitary manner. This had the potential to affect all residents residing in the facility. The facility census was 88.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, record review, and review of the facility policy the facility failed to ensure hand hygiene was completed during medication administration for Resident's #9, #57 and #64 and failed to ensure Resident #31's soiled linens and soiled incontinence brief was not placed on the floor during incontinence care. This affected three residents (#9, #57 and #64) out of seven reviewed for medication administration and one resident (#31) of three residents reviewed for incontinence care. The census was 88.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, record review, and policy and procedure review, the facility failed to ensure residents received timely assistance getting dressed and hair shampooed per physician order. This affected one resident (#60) of three residents reviewed for activities of daily living (ADL). The facility census was 88.
- 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, and review of the facility policy the facility failed to ensure Resident #85's neuro checks were completed as scheduled after a fall. This affected one resident (#85) out of four residents reviewed for falls. The facility census was 88.
- 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, interview, record review, and policy and procedure review, the facility failed to ensure timely incontinence care. This affected one resident (#13) of one resident reviewed for bowel and bladder incontinence. The facility census was 88.
September 6, 2023Complaint inspection · 1 citation
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on record review and interview the facility failed to administer insulin as ordered. This affected three (Resident #7, #8, #9) of eight residents who required insulin. The census was 75.
February 7, 2022Standard inspection · 0 citations
July 25, 2019Standard inspection · 3 citations
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, record review and interview the facility failed to ensure call lights were within reach and accessible for Resident #25, #46 and #64. This affected three residents (#25, #46 and #64) of 32 residents reviewed for call light placement. Findings Include: 1. Record review revealed Resident #25 was admitted to the facility with diagnoses that included traumatic brain injury, heart failure and pneumonia. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #25 was severely cognitively impaired and required extensive assistance of activities of daily living. Observation of Resident #25 on 07/25/19 at 9:17 A.M. revealed Resident #25 was laying in bed with his eyes open. The call light was noted to be clipped around the call cord approximately six inches from the call light shut off switch and out of reach of Resident #25. [...]
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, record review and interview the facility failed to maintain a medication error rate of less than five percent. The medication error rate was calculate to be 9.37% and included three medication errors of 32 medication administration opportunities. This affected one resident (#40) of six residents observed for medication administration.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review and interview the facility failed to ensure intravenous (IV) medications were administered in a way that preserved proper infection control. This affected one resident (#282) of six residents observed for medication administration.
Fire safety inspections
15 fire safety citations on file: 1 on July 6, 2026, 4 on March 25, 2024, 5 on February 7, 2022, 5 on July 25, 2019.
Every fire safety citation15 citations
- E
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · July 6, 2026 · Corrected (the home has a date of correction)
- F
Meet requirements for sections of health care facilities separated by fire resistive construction.
K 131 · March 25, 2024 · Corrected (the home has a date of correction)
- 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 · March 25, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 25, 2024 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · March 25, 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 7, 2022 · 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 · February 7, 2022 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · February 7, 2022 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · February 7, 2022 · Corrected (the home has a date of correction)
- E
Meet requirements for the use and maintenance of medical gas equipment.
K 922 · February 7, 2022 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 25, 2019 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · July 25, 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 · July 25, 2019 · Corrected (the home has a date of correction)
- E
Meet other general requirements that are deficient.
K 500 · July 25, 2019 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · July 25, 2019 · Corrected (the home has a date of correction)