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 36 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
24D
4E
7F
Potential for minimal harm
0A
0B
0C
September 15, 2025Standard inspection, Complaint inspection · 16 citations
- F
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, observations, resident and staff interviews, review of dietary spreadsheets, review of guidelines for pureeing food, and policy review, the facility failed to ensure residents received enough food to meet their needs and preferences, serve portions sizes as planned on the menu, ensure pureed food was prepared in a manner to maintain the nutritive value of the food, and ensure posted menus were updated for the residents to view what meals they were having for the day. This affected Resident #3 and had the potential to affect 65 of 66 residents. The facility identified one resident (#9) who did not receive food from the kitchen. The facility census was 66.
- F
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, resident and resident representative interviews, and staff interview, the facility failed to ensure residents received foods that were palatable. This had the potential to affect 65 of 66 residents. The facility identified one resident (#9) who did not receive food from the kitchen. The facility census was 66.
- 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, staff interview, and policy review, the facility failed to ensure food was stored in a manner to protect against the potential spread of foodborne illness. The facility also failed to ensure staff wore hair restraints in the kitchen. The facility also failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect 65 of 66 residents in the facility. The facility identified one resident (#09) who did not receive food from the kitchen. The facility census was 66.
- F
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on review of the facility's quality assurance performance improvement (QAPI) meeting sign-in sheets, review of the facility's QAPI meetings policy, and staff interview, the facility failed to ensure required QAPI team member were present at meetings. The had the ability to affect all 66 residents 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, policy review, resident interview, and staff interview, the facility failed to maintain a clean, sanitary, and safe environment for all residents. This affected Residents #4 and #31 and had the potential to affect all 66 residents residing in the facility.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on record review, observation, staff interview, policy review, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to follow physician orders for contact isolation precautions for Residents #57 and #13. This affected Residents #57 and #13 and had the potential to affect the residents residing on their units, 100 and 200 halls. The facility census was 66.
- D
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 record review, policy review, observations, and resident and staff interviews, the facility failed to ensure all residents were provided with a safe, clean and homelike environment. This affected two (#13 and #25) of two residents reviewed for homelike environment. The facility census was 66.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review, staff interview, review of Self-Reported Incidents (SRI), and facility policy review, the facility failed to ensure all alleged violations of staff-to-resident physical abuse were reported timely to administration and the State Survey Agency. This affected one (#40) of five residents reviewed abuse. The facility census was 66.
- 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 and staff interview, the facility failed to ensure admission comprehensive Minimum Data Set (MDS) assessments were completed within the required timeframes. This affected three (#3, #25, and #39) of three residents reviewed for resident assessment. The facility census was 66.
- 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 medical record review, staff interview, and policy review, the facility failed to ensure resident care plans were complete and specific to each resident. This affected two (#3 and #55) of six residents reviewed for care planning. The facility census was 66.
- 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 medical record review, staff interview, and policy review, the facility failed to ensure care plans were updated timely to reflect new diagnoses, new sexual behaviors, and medications to treat the new diagnoses and behaviors. This affected two (#45 and #57) of six residents reviewed for care planning. The facility census was 66.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on record review, observation, resident interview, staff interview, and policy review, the facility failed to ensure residents who required assistance with activities of daily living received adequate assistance with nail care. This affected one (#22) of two residents reviewed for ADLs. The facility census was 66.
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on record review, observation, resident and staff interviews, and policy review, the facility failed to ensure activities met the needs and preferences of the residents. This affected one (Resident #77) of two residents reviewed for activities. The facility census was 66.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review, observation, resident and staff interviews, review of U.S. Food and Drug Administration (FDA) guidance, and policy review, the facility failed to ensure residents vaped in the facility's designated smoking area. This affected one (Resident #11) of two residents reviewed for supervision. The facility census was 66.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, staff interviews, and policy review the facility failed to ensure the medication error rate did not exceed five percent (%). There were two observed errors out of 34 opportunities that resulted in a medication error rate of 5.88%. This affected one (Resident #42) out of four residents reviewed for medication administration. The facility census was 66.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure medical records were complete and accurate. This affected one (#3) of 23 residents reviewed medical record accuracy. The facility census was 66.
July 12, 2024Complaint inspection · 5 citations
- F
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 observation, staff interview, review of the facility menu and spreadsheet and policy review, the facility failed to ensure menus were followed. This had the potential to affect 59 of 59 residents who receive their meals from the kitchen, the facility identified two residents (#25 and #31) that received no food by mouth. The facility census was 61.
- 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, staff interview, record review, the facility failed to ensure food items were stored in a sanitary manner. This had the potential to affect 59 of 59 residents who receive their meals from the kitchen, the facility identified two residents (#25 and #31) that received no food by mouth. The facility census was 61.
- 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, observations, staff and resident interviews and policy review, the facility failed to ensure medications were stored securely. This affected five (#18, #29, #32, #55 and #56) out of five residents reviewed for medication storage. This had the potential to affect four (#29, #48, #10 and #57) residents that the facility identified as cognitively impaired and independently mobile. The facility census was 61.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on medical record review and staff interviews, the facility failed to ensure a resident's admission assessments were timely completed in the electronic health record. This affected one (#300) out of three residents reviewed for medical record accuracy and completeness. The facility census was 61.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on medical record review, observations, staff interviews and policy review, the facility failed to ensure staff completed hand hygiene during during incontinence care. This affected one (#06) out of three residents reviewed for incontinent care. The facility census was 61.
February 29, 2024Complaint inspection · 1 citation
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review, review of the facility's Self-Reported Incident (SRI), review of the facility policy, and staff interview, the facility failed to report resident-to-resident physical abuse to the State Survey Agency, the Ohio Department of Health. This affected two (Residents #1 and #2) of four residents reviewed for abuse. The facility census was 55.
December 12, 2023Complaint inspection · 2 citations
- 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 record review, staff interview, and review of the facility policy, the facility failed to notify the physician and resident representative of the resident's severe weight losses. This affected two (Residents #200 and #500) of six residents reviewed for weight loss. The facility census was 54.
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on record review, staff interview, and review of the Medline guidance, the facility failed to provide the care and services for a resident's peripherally inserted central catheter (PICC). This affected one (Resident #200) of three residents reviewed for intravenous (IV) therapy. The facility census was 54.
February 14, 2023Standard inspection · 8 citations
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to respond to an acute change in condition, including an elevated temperature for Resident #49 in a timely manner. Actual harm occurred on 01/27/23 when Resident #49, who was in a persistent vegetative state and dependent on staff for all activity of daily living care, was transferred to hospital and admitted for treatment of pneumonia requiring intravenous (IV) antibiotics. The resident had been initially assessed to have an elevated temperature on 01/25/23 of 101.3 with no evidence of physician notification, comprehensive assessment or treatment. The resident was hospitalized until 02/02/23. The facility's census was 51.
- 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 observations, staff interviews, and review of the facility policy, the facility failed to ensure proper storage of medications by ensuring expired medications were not being used. This affected six residents (#2, #4, #7, #15, #34, #155) who facility identified as receiving the expired medications from two medication carts and a medication storage room in the facility. The facility census was 51.
- 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 review of facility policy, the facility failed to notify the physician of Resident #49's elevated temperature for two days. This affected one (Resident #49) of three residents reviewed for physician notification. The facility's census was 51.
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on medical record review, observations, staff interviews, and review of facility policy, the facility failed to provide activities to residents residing in the facility's Memory Care Unit (MCU). This affected three (Residents #25, #35, and #41) of three residents reviewed for activities. The facility's census was 51.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the faciltiy failed to assess pressure ulcers on a weekly basis to include wound measurments and description of the wounds. This affected two (Residents #30 and #37) of four residents reviewed for pressure ulcers. The facility identified four (Residents #29, #30, #37, and #39) with pressure ulcers. The facility's census was 51.
- 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 medical record review, observation, and staff interview, the facility failed to ensure an ordered orthotic therapeutic device was applied to assist with a resident's contracture. This affected one (Resident #49) observed for application of therapeutic devices. The facility identified 25 residents with contractures. The facility's census was 51.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on medical record review, observation, staff interview, and review of facility policy, the facility failed to provide supervision and failed to implement interventions for a resident who smoked. This affected one (Resident #45) of five residents identified to smoke. The facility's census was 51.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on record review, staff interviews, and review of facility policies, the facility failed to maintain appropriate infection control techniques during tracheostomy (trach) care. This affected one resident (#49) of the two residents identified by the facility as requiring tracheostomy care. The facility also failed to utilize proper hand hygiene during wound care. This affected one Resident (#49) of the four residents identified with wounds and requiring dressing changes. The facility census was 51.
December 12, 2019Standard inspection · 4 citations
- 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 medical record review, observation, and staff interview, the facility failed to develop and/or implement each resident's plan of care related to contracture management, diabetes management and insulin use, use of an anti-platelet medication, and for medications used to managed inappropriate behaviors. This affected four (#04, #07, #52, and #63) of 20 residents' whose care plans were reviewed. The census was 66 residents.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on medical record review, observation, and representative/family interview and staff interview, the facility failed to ensure that one resident received treatment and care to maintain proper and comfortable positioning while in a wheel chair. This affected one (Resident #16) of three residents reviewed for positioning/mobility.
- 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 medical record review, observation, and staff interview, the facility failed to ensure that a resident with a limited range of motion received appropriate treatment to prevent further decreases in range of motion and to improve comfort. This involved one (Resident #04) of three residents reviewed for positioning/mobility.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on medical record review and staff interview the facility failed to ensure a resident was monitored for sexual behaviors related to the use of medication. This affected one (Resident #07) of six residents reviewed for unnecessary medications. The facility census was 66.
Fire safety inspections
21 fire safety citations on file: 6 on September 15, 2025, 8 on February 14, 2023, 7 on December 12, 2019.
Every fire safety citation21 citations
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · September 15, 2025 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · September 15, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · September 15, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 15, 2025 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · September 15, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · September 15, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · February 14, 2023 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
K 354 · February 14, 2023 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · February 14, 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 · February 14, 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 · February 14, 2023 · 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 14, 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 · February 14, 2023 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · February 14, 2023 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · December 12, 2019 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · December 12, 2019 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · December 12, 2019 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · December 12, 2019 · 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 · December 12, 2019 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · December 12, 2019 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 12, 2019 · Corrected (the home has a date of correction)