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
0J
0K
0L
Actual harm
3G
0H
0I
Potential for more than minimal harm
20D
1E
1F
Potential for minimal harm
0A
0B
1C
February 12, 2026Standard inspection · 0 citations
October 10, 2025Complaint inspection · 7 citations
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on review of the clinical record and interviews, facility staff failed to fully inform the Power of Attorney (POA) of a resident before conducting a diagnostic procedure. This finding was evident for one (Resident #16) out of six residents reviewed for injury of unknown origin during this complaint survey.
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on surveyor observation and interview with staff, it was determined that the facility staff failed to protect the privacy of residents' medical information. This was found to be evident in 1 out of 3 nursing units observed during a complaint survey.
- 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 records review and staff interview, it was determined the facility staff failed to revise interdisciplinary care plans to reflect accurate interventions for residents. This was evident for one (Resident #21) of the six residents reviewed for injuries of unknown origin during this complaint survey.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on review of a complaint and of the medical record, interviews with facility staff, and observation, it was determined the facility failed to provide assistive devices to residents that would allow the residents the ability to achieve the greatest independence with performing Activities of Daily Living (ADL). This was evident for 1 (#312111 regarding Resident #8) of 5 complaints reviewed during the complaint survey.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of a complaint and of the medical record, interviews with facility staff, and observation, it was determined the facility failed to provide supplements as documented in a resident's care plan and Dining Detail. This was evident for 1 (#312111 regarding Resident #8) of 5 complaints reviewed during the complaint survey.
- D
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Inspectors wroteBased on investigation of complaints, medical records review, and staff interviews, it was determined that the facility failed to coordinate care for a resident receiving hospice services. This was evident that one (Resident #16) of 22 residents reviewed for their care during this complaint survey.
- D
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Inspectors wroteBased on review of facility reported incidents, review of employee records, and interview with facility staff, it was determined that the facility failed to have documentation that a Care Associate (CA) was given abuse training after returning from suspension related to an allegation of abuse. This was evident for 1 (CA #18) of 2 Care Associates records reviewed during this complaint survey.
September 6, 2024Standard inspection, Complaint inspection · 11 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 medical record review, staff interviews, and review of facility investigation documents, it was determined that the facility failed to ensure that residents remained free of abuse and neglect. This failure led to physical abuse and harm of Resident #135. This finding was evident for 5 of 34 (Resident #135, #130, #117, #122, #125) residents reviewed for abuse during the survey.
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on medical record review, staff interviews, and review of facility investigation documents, it was determined that the facility failed to provide adequate supervision to Resident #132 who had a documented history of wandering, agitation, and physically aggressive behaviors as evidenced by the physical abuse and harm of Resident #135. This was evident for 1 (Resident #132) of 4 residents reviewed for accidents and adequate supervision during the survey.
- G
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on medical record review, administrative reviews, and staff interview, it was determined that facility staff failed to monitor and implement interventions to address the nutritional needs of residents who had a known significant weight loss. This deficient practice was evident for 5 (#127 and #22, #17, #40, #33) out of 15 residents reviewed for nutrition. The failure resulted in harm to Resident #127.
- F
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wrote5. On 09/03/24 at 3:00 pm review of the facility's investigation of Resident #122 alleged allegation of abuse revealed there was not a date on the reporting form to verify when the facility reported the incident to the state agency. There was no email to verify the date and time the incident was sent to OHCQ. Administrator #1 was made aware and asked to provide documentation of when the state agency was made aware of the allegation of abuse. On 09/04/24 at 08:16 am received a copy of the email when the incident concerning Resident #122 was reported to OHCQ. The incident was reported on 12/20/23 at 1:30 pm. Per documentation provided by the facility, Administrator #1 was made aware of the incident on 12/20/23 at 9:30 am. The alleged allegation of abuse was reported to the state agency outside the allotted 2-hour timeframe. 6. [...]
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, staff interviews and record review, it was determined that the kitchen failed to store food items so as to maintain the integrity of the specific item and failed to wear gloves while preparing food. This was observed during the initial tour of the kitchen.
- 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 interviews, and staff interviews, It was determined that the facility failed to treat the resident with dignity by improperly turning the resident. This was evident for 1 (resident #5) of 9 residents reviewed for dignity.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observations and staff interview, the facility failed to accommodate the resident's (#22) dietary needs. This was evident for 1 of 2 residents reviewed for nutrition.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on review of records and interview with facility staff, it was determined that the facility failed to ensure that staff reported suspected abuse to the administration in a timely manner resulting in the alleged perpetrator being allowed to continue to provide services to the victim prior to the initiation of the investigation. This was evident for 1(Resident #28) out of 8 residents reviewed for abuse during the recertification survey.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on medical record review and interviews it was determined that the facility staff failed to follow professional nursing standards as evidenced by nursing staff failure to sign the medication record after an antibiotic was administered. This deficient practice was evident in 1 (#123) of 2 medical records reviewed for medication administration during the survey.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on medical record review and interview it was determined that the facility staff failed to administer antibiotic therapy as ordered for a resident. This deficient practice was evident in 1 (#123) of 2 resident records reviewed for medication administration during the survey.
- 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 and interview it was determined the facility staff failed to provide documentation to verify a resident received a shower during their admission. This deficient practice was evident in 1 (#123) of 1 resident record reviewed for showers during the survey.
October 11, 2019Standard inspection · 8 citations
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation and staff interview it was determined that the facility staff failed to ensure residents were fed at the same time. This was evident for 2 out of 4 dining observations. The evidence includes: This surveyor observed dining on the Cottonwood unit on 10/3/19. Residents seated at tables #13 and #17 (the tables were butted up against each other) were observed eating at 11:48 AM while Residents # 7 and # 102 were seated and waiting for their food. Resident # 102 was served at 11:59 AM and Resident # 7 was served at 12:05 PM. This surveyor observed dining on the Cottonwood unit on 10/04/19. Two residents were observed at tables # 13 and #17 eating at 11:55 AM. Residents # 102 and Resident # 7 were observed seated waiting for their food and not served their lunch until 12:03 PM. The Administrator and Director of Nursing were interviewed on 10/10/19 at 8:52 AM. [...]
- 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 surveyor observation it was determined that the facility failed to provide a safe, clean, comfortable and homelike environment. This was evident for 1 bathing room and 1 hallway in the facility.
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to notify the resident or responsible party in writing of the reason for Resident (#152) transfer to the hospital. This was evident for 1 of 2 resident reviewed for hospitalization during the annual recertification survey and 1 out of 71 residents selected for review during the survey process.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on medical record review and staff interview it was determined the facility staff failed to document accurate assessment for Resident (#20) on the MDS. This was evident for 1 of 1 resident selected for review of restraints and 1 of 71 residents selected for review of MDSs assessment during the annual survey process. The MDS is a federally mandated assessment tool that helps nursing home staff gathers information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. Categories of MDS (Minimum Data Set) are: [...]
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on clinical record review and staff interview it was determined that the facility staff failed to immediately place oxygen on a resident who needed it. This was evident for 1 out of 2 residents reviewed as part of the complaint process.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to obtain weights as ordered for Resident (#152). This was evident for 1 of 71 residents selected for review during the survey process. Medical record review for Resident #152 revealed on 7/1/19 the physician ordered: weight daily x3 days and then 3 times a week for acute CHF diagnosis. Congestive heart failure (CHF) is a chronic progressive condition that affects the pumping power of the heart muscles. While often referred to simply as heart failure, CHF specifically refers to the stage in which fluid builds up around the heart and causes it to pump inefficiently. [...]
- D
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observation it was determined that the facility failed to maintain an effective pest control program as evidenced by the presence of a mouse. This deficient practice has the potential to affect all residents.
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation On 10-3-19 during the annual recertification survey it was determined the facility failed to post the required nursing staffing data in a readily accessible area for residents and visitors at any given time. This was evident on 1 out of 4 nursing assignment boards
Fire safety inspections
11 fire safety citations on file: 1 on February 12, 2026, 8 on September 6, 2024, 2 on October 11, 2019.
Every fire safety citation11 citations
- F
Have simulated fire drills held at unexpected times.
K 712 · February 12, 2026 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · September 6, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · September 6, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 6, 2024 · Corrected (the home has a date of correction)
- F
Have elevators that firefighters can control in the event of a fire.
K 531 · September 6, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · September 6, 2024 · 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 · September 6, 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 · September 6, 2024 · Corrected (the home has a date of correction)
- E
Install properly constructed and protected linen or trash chutes.
K 541 · September 6, 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 · October 11, 2019 · Corrected (the home has a date of correction)
- D
Have restrictions on the use of portable space heaters.
K 781 · October 11, 2019 · Corrected (the home has a date of correction)