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 19 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
12D
5E
0F
Potential for minimal harm
0A
0B
0C
August 8, 2025Standard inspection, Complaint inspection · 8 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 interview, record review, and facility document and policy review, the facility failed to protect 3 (Resident #55, Resident #58, and Resident #53) of 3 residents ' right to be free from physical/mental abuse by another resident. On 05/26/2025, before the evening meal in the dining room, dietary staff observed Resident #95 attempt to hit their roommate, Resident #55. Dietary staff separated the residents and instructed the residents to go upstairs. Later that evening, staff transferred Resident #55 to the emergency department (ED) due to bleeding from the resident ' s head. While at the ED, Resident #55 stated that Resident #95 hit them multiple times with a cane. This resulted in Actual Harm when Resident #55 was hospitalized and diagnosed with a fractured right arm, received six sutures to a laceration to their head, and was diagnosed with acute blood loss anemia. [...]
- G
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to implement their policy for abuse prohibition for 1 (Resident #55) of 2 residents. Specifically, a dietary aide (DA) witnessed Resident #95 attempt to hit Resident #55 in the dining room on 05/26/2025. The staff member separated the residents and directed them to return to the unit where they resided; however, the incident was not reported to the Director of Nursing (DON), the nurse supervisor on duty, or Administrator as required per facility policy. Once Resident #55 returned to their room, the resident stated that Resident #95 struck them in their head with a cane. [...]
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure 1 (300 hall) of 2 shower rooms were maintained in a clean condition.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, record review, facility policy, and facility document review, the facility failed to consistently implement a program to ensure resident safety while smoking for 6 (Residents #6, #9, #4, #24, #31, and #49) of 29 residents who smoked. Specifically, the facility failed to ensure residents did not keep smoking materials in their possession and did not give smoking materials to other residents per the facility's smoking policy and smoking agreement.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on interview, record review, and facility document and policy review, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN, Form CMS [Centers for Medicare & Medicaid Services] - 10055) for 1 (Resident #14) of 3 residents reviewed for Medicare Beneficiary Protection Notification when discharged from Medicare Part A Services with benefit days remaining.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview, record review, facility document review, and facility policy review, the facility failed to report an incident of abuse to the Administrator and to the state survey agency within two hours for 1 (Resident #55) of 2 residents reviewed for abuse. Resident #55 was struck on the head with a metal cane by Resident #95, which resulted in bleeding from a head injury requiring transfer to the hospital for evaluation.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview, record review, document review, and facility policy review, the facility failed to have evidence that an allegation of abuse was thoroughly investigated for 1 (Resident #55) of 3 sampled residents reviewed for abuse. Specifically, on 05/26/2025, Resident #55 was transferred to the emergency department (ED) due to bleeding from their head. Prior to leaving the facility, Resident #55 did not report how the injury occurred; however, the resident's roommate, Resident #95 reported that the resident sustained the injuries from a fall. After arrival at the ED, where Resident #55 was diagnosed with a fractured right arm, a laceration to the head with an arterial bleed, and acute blood loss anemia, the resident told hospital staff that the injuries were a result of Resident #95 hitting them multiple times with a cane. [...]
- 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 keep fingernails trimmed and clean for a resident (Resident #33) who was dependent on staff for activities of daily living (ADLs).
August 27, 2024Complaint inspection · 3 citations
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on record review, resident and staff interview the facility failed to treat one (#48) of three reviewed in a dignified manner. The facility census was 85. Findings Included: Review of the medical record revealed Resident #48 was admitted [DATE]. Diagnoses included vascular dementia, type two diabetes, and lumbago with sciatica. Review of the minimum data set (MDS) dated [DATE] revealed Resident #48 had a Brief Interview of Mental Status score of 08 that indicated the resident was cognitively impaired. Review of email dated 08/05/24 written by the Administrator revealed he had spoken to the Dietician #204 with the referencing an encounter with Resident #48. The Dietician stated she had realized what she had said, was very sorry and that the phrase was her common refrain when giving a banana to her grand kids. Dietician #204 was extremely remorseful, almost to the point of tears. [...]
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure a wound treatment was completed as ordered. This affected one resident (#81) of three residents reviewed. The facility census was 85. Findings Included: Review of the medical record revealed Resident #81 admitted on [DATE]. Diagnoses included chronic osteomyelitis right ankle and foot, and diabetes mellitus. Review of the minimum data set assessment (MDS) dated [DATE] revealed Resident #81 was cognitively intact with a Brief Interview of Mental Status score of 15. Review of physician order dated 08/14/24 revealed right heel wound care was ordered as follows: cleanse with normal saline and pat dry. Apply betadine and let air dry, apply calcium alginate with silver to the wound bed, cover with abdominal dressing, then wrap with Kerlix and apply ace wrap to right foot every day. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure enhanced barrier precautions were implemented and the facility failed to complete hand hygiene during wound care. This affected one resident (#81) of three residents reviewed. The facility census was 85. Findings Included: Review of the medical record revealed Resident #81 admitted to the facility on [DATE]. Diagnoses included chronic osteomyelitis right ankle and foot, and diabetes mellitus. Review of the minimum data set assessment (MDS) dated [DATE] revealed that Resident #81 was cognitively intact with a Brief Interview of Mental Status score of 15. Review of physician order dated 08/14/24 revealed that Resident #81 treatment for the right heel was as follows: cleanse with normal saline and pat dry. [...]
May 13, 2024Complaint inspection · 1 citation
- 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 medical record review, staff interview, observations, and policy review, the facility failed to appropriate treatment and services for care of a resident who was incontinent of bowel and had a indwelling urinary catheter. This affected one (#45) of three residents reviewed for incontinence and catheter care. The facility identified there were 48 residents who were incontinent of bowel and five residents with indwelling catheters.
March 21, 2024Standard inspection · 3 citations
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to accurately complete an updated pre-admission screening and resident review (PASARR) for residents with a diagnosis change. This affected one (#27) of three residents reviewed for PASARR. The facility census was 83.
- 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 review of the medical record, staff interviews, and policy review, the facility failed to complete care conferences as required. This affected two residents (#27 and #58) of 24 residents reviewed. The facility census was 83.
- 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 observations, medical record review, staff interviews, and policy review, the facility failed to ensure a safe, clean, and home-like environment. This affected two (#2 and #27) of 24 residents reviewed for environment. The facility census was 83.
December 7, 2023Complaint inspection · 3 citations
- E
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of the State of Ohio Board of Pharmacy Terminal Distributor Licensure of Prescriber Practices, and staff interviews, the facility failed to ensure medications administered Intravenously (IV) were obtained from a source with a Terminal Distributor of Dangerous Drugs (TDDD) license (which allows a business entity to purchase, possess, and/or distribute dangerous drugs at a specific location) specific to the State of Ohio. This deficiency affected four (Residents #13, #22, #72, and #80) out of four residents reviewed for IV medication administration. [...]
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of the State of Ohio Board of Pharmacy Terminal Distributor Licensure of Prescriber Practices, and staff interviews, the facility failed to ensure medications were obtained from a source with a Terminal Distributor of Dangerous Drugs (TDDD) license (which allows a business entity to purchase, possess, and/or distribute dangerous drugs at a specific location) specific to the State of Ohio. This deficiency affected four (Residents #13, #22, #72, and #80) out of four residents that were reviewed for medications administered by a contracted ancillary provider. [...]
- 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 wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of the State of Ohio Board of Pharmacy Terminal Distributor Licensure of Prescriber Practices, staff interviews, and review of the facility policy, the facility failed to ensure a contracted entity had appropriate State of Ohio required credentials for provision of services for residents. This deficiency affected four (Residents #13, #22, #72, and #80) out of four residents that were reviewed for medications administered by a contracted ancillary provider. [...]
March 5, 2020Standard inspection · 1 citation
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on medical record review, observation, staff interviews and facility policy review the facility failed to store respiratory equipment in a clean and sanitary manner. This affected one (Resident #29) of one resident reviewed for respiratory care. The census was 83.
Fire safety inspections
24 fire safety citations on file: 7 on August 8, 2025, 11 on March 21, 2024, 6 on March 5, 2020.
Every fire safety citation24 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 8, 2025 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · August 8, 2025 · 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 · August 8, 2025 · 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 · August 8, 2025 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · August 8, 2025 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · August 8, 2025 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · August 8, 2025 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · March 21, 2024 · Corrected (the home has a date of correction)
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · March 21, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 21, 2024 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · March 21, 2024 · 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 · March 21, 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 · March 21, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · March 21, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 21, 2024 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · March 21, 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 · March 21, 2024 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of portable space heaters.
K 781 · March 21, 2024 · Corrected (the home has a date of correction)
- F
Meet other general requirements.
K 100 · March 5, 2020 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 5, 2020 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 5, 2020 · 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 · March 5, 2020 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · March 5, 2020 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · March 5, 2020 · Corrected (the home has a date of correction)