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 27 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
16D
8E
2F
Potential for minimal harm
0A
1B
0C
June 2, 2026Standard inspection, Complaint inspection · 11 citations
- F
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on review of the food committee minutes, observation, interviews, and review of the ServSafe guidelines, the facility failed to ensure that residents received food at palatable temperatures. This deficient practice had the potential to affect all residents except those who received nothing by mouth, residents (#69, #110, and #207). The facility census was 170.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations and interviews, the facility failed to ensure the nursing unit kitchenettes were maintained in a clean and sanitary manner and food was properly labeled and dated. This had the potential to affect except three residents (#69, #110, and #207) who received nothing by mouth. The facility census was 170.
- 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 observations, interviews, and review of the facility policy and procedure, the facility failed to ensure a clean and sanitary resident environment affecting 44 residents (#4, #8, #9, #11, #12, #13, #18, #19, #26, #29, #32, #33, #41, #45, #48, #50, #57, #58, #65, #76, #79, #102, #104, #109, #110, #114, #127, #133, #136, #141, #146, #147, #155, #158, #160, #171, #175, #178, #182, #188, #190, #192, #201, and #205) of 44 residents that resided on the Rosewood unit and had the potential to affect all 170 residents residing in the facility.
- E
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and interview, the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were completed accurately for four residents (#9, #22, #88, and #142) of four residents reviewed for smoking assessments. The facility census was 170.
- E
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on record review, observation, facility policy review, and interview, the facility failed to ensure orders were in place for oxygen therapy and failed to ensure oxygen therapy orders were implemented appropriately. This finding affected four residents (#95, #122, #207 and #236) of four residents reviewed for oxygen therapy. The facility census was 170.
- 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 observation, interview and facility policy review, the facility failed to ensure medications were stored appropriately, expired medications were discarded appropriately, and insulin medications were dated and had residents' names on the insulin vials or KwikPens as appropriate. This finding affected one (Resident #120) of 41 residents who receive medications on the Silverpine unit; seven (Residents #4, #9, #13, #102, #155, #160 and #190) of seven residents who receive insulin from the Rosewood unit back hall medication cart; one (Resident #8) of one resident on the Rosewood unit who receives vitamin B-6; one (Resident #189) of 24 residents who receive medications on the Oakwood unit; and three new admissions (Residents #136, #190 and #205) who received tuberculin testing on the Rosewood unit. The facility census was 170.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #233's medications were administered as ordered by the physician. This finding affected one resident (#233) of four residents reviewed for medication administration. The facility census was 170.
- 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, observation, interviews, and facility policy review, the facility failed to ensure that indwelling urinary catheter care was completed every shift as ordered and as required by facility policy, resulting in significant accumulation of smegma (body secretion made of oils, sweat, and dead skin cells) and increased risk of infection for one resident (#56) of three reviewed for catheter use. The facility census was 170.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure timely re-weights were obtained and the physician/nurse practitioner were notified of significant weight loss in a timely manner. This affected one resident (#127) of three residents reviewed for weight loss. The facility census was 170.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure Resident #217's controlled medications were appropriately monitored and tracked by the facility. This finding affected one resident (#217) of four residents reviewed for medication administration. The facility census was 170.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on record reviews, observations, interviews and facility policy review, the facility failed to ensure enhanced barrier precautions (EBP) were maintained per order. This affected two residents (#176, #207) out of four residents reviewed for isolation precautions. The facility census was 170.
March 3, 2025Complaint inspection · 1 citation
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on medical record review, observation, staff interview, and review of the facility's Coronavirus (COVID-19) policy, the facility failed to ensure personal protective equipment (PPE) was donned correctly for Resident #193, who was on droplet precautions to potentially prevent the spread of COVID-19 infections. This had the potential to affect 29 residents (Residents #165, #166, #167, #168, #169, #170, #171, #172, #173, #174, #175, #176, #177, #178, #179, #180, #181, #182, #183, #184, #185, #186, #187, #188, #189, #190, #191, #192, and #193) who resided on the Sandalwood unit. The facility census was 189.
September 13, 2024Complaint inspection · 1 citation
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Resident #135's nails were clean, and her chin was free of hair. This affected one resident (Resident #135) out of three residents (Residents #51, #135, and #187) reviewed for activities of daily living (ADLs). The facility census was 158.
June 6, 2024Standard inspection · 2 citations
- 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 observation, interview, record review, and facility policy review revealed the facility failed to ensure multiple dose medications were dated when opened. This affected five residents (#39, #54, #81, #88 and #285) of 15 residents reviewed with insulin pens and two medication carts (Rosewood back and Oakwood front) of five medication carts reviewed. The facility census was 181. Findings Included: 1. Review of the medical record revealed Resident #285 was admitted to the facility on [DATE] with a diagnosis of type II diabetes. Review of the physician orders for June 2024 revealed an order for Insulin Glargine (long-acting insulin)100 unit/milliliter (ml) solution pen-injector. Observation on 06/06/24 at 10:01 A.M. of Oakwood front medication cart revealed Resident #285's insulin Glargine pen was dispensed on 04/25/24 and not dated to indicate when it was opened. [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, record review, and facility policy review the facility failed to ensure recommended guidelines were followed for changing disposable respiratory equipment for Residents #12, #15, and #83. This affected three residents (#12, #15, and #83) of six residents reviewed for respiratory care. The facility census was 181.
April 3, 2024Complaint inspection · 3 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review the facility failed to ensure wound treatments were completed as ordered. This affected one of three residents (Resident #152) reviewed for wound treatments. The facility census was 171. Findings Included: Review of the medical record for Resident #152 revealed an admission date of 09/06/22. Diagnoses included but were not limited to diabetes mellitus, dependence on renal dialysis, depression, pulmonary hypertension, absence of right leg below the knee, and calciphylaxis (calcium accumulates in small blood vessels of the fat and skin tissues). Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/10/24, revealed Resident #152 had intact cognition and was dependent or required maximal assistance for activities of daily living. [...]
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on medical record review and interview the facility failed to ensure Resident #152 was not administered expired medication (budesonide) and the medication was available for administration. This affected one of three residents (Resident #152) reviewed for medication administration. The facility census was 171. Findings Included: Review of the medical record for Resident #152 revealed an admission date of 09/06/22. Diagnoses included but were not limited to eosinophilic esophagitis (an allergic inflammatory condition of the esophagus), diabetes mellitus, and dependence on renal dialysis. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/10/24, revealed Resident #152 had intact cognition. [...]
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on medical record review and interview the facility failed to ensure Resident #152 received an anticoagulant medication to prevent the formation of blood clots as ordered. This affected one of three residents (Resident #152) reviewed for medication administration. The facility census was 171. Findings Included: Review of the medical record for Resident #152 revealed an admission date of 09/06/22. Diagnoses included but were not limited to diabetes mellitus, dependence on renal dialysis, pulmonary hypertension, absence of right leg below the knee, and calciphylaxis (calcium accumulates in small blood vessels of the fat and skin tissues. Calciphylaxis causes blood clots, painful skin ulcers and may cause serious infections that can lead to death.) Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/10/24, revealed Resident #152 had intact cognition. [...]
November 8, 2023Complaint inspection · 3 citations
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, record review, review of the facility policy and review of the Centers for Disease Control (CDC) and Prevention guidelines, the facility failed to maintain an adequate infection control program to prevent the spread of infection. The facility failed to ensure staff donned appropriate personal protective equipment (PPE) prior to entering the room of and providing wound care to Resident #156 who had tested positive for Carbapenem-resistant Acinetobacter baumannii (CRAB). Furthermore, the facility failed to ensure Resident #155, who tested positive for CRAB washed his hands before leaving his room. [...]
- D
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Inspectors wroteBased on interview, record review and review of the facility policy, the facility failed to ensure Resident #172 and his Responsible Party were given a transfer notice when Resident #172 was transported from the facility via Emergency Medical Services to the local hospital for evaluation. This affected one resident (Resident #172) out of three residents reviewed for transfers and discharges. The facility census was 170.
- 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 interview, record review and review of the facility policy the facility failed to ensure Resident #172 and his Responsible Party were given a bed hold notice and transfer notice when Resident #172 was transported from the facility via Emergency Medical Services to the local hospital for evaluation. This affected one resident (Resident #172) out of three residents reviewed for transfers and discharges. The facility census was 170.
April 27, 2023Standard inspection · 6 citations
- 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 and staff interview the facility failed to ensure a clean and well maintained environment. This affected 41 of 167 facility residents, Residents #15, #19, #22, #26, #35, #37, #38, #40, #47, #52, #59, #63, #69,#72, #73 #78, #79, #84, #87, #89, #90, #97, #98, #99, #107, #109, #110, #112, #119, #123, #124, #128, #129, #141, #145, #148, #149, #151, #560, #561 and #563 . The facility census was 167. Findings Include: During an environment tour with Housekeeping Director (HSD) #540 on 04/27/23 between 11:07 A.M. and 11:25 A.M. The following was observed and verified with HSD #540. 1. The privacy curtains of the rooms occupied by Residents #15, #19, #38, #40, #47, #52, #63, #69, #72, #79, #87, #89, #90, #98, #99, # #107, #109, #110, #112, #119, #123, #124, #128, #141, #145, #148, #149, #151, #560, #561 and #563 had significant levels of unknown substances and stains. 2. [...]
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on record review and interview the facility failed to implement their abuse policy and procedure in regards to reporting allegations of misappropriation to the Ohio Department of Health. This affected one resident (#180) of three residents (#33, #148, and #180) reviewed for abuse, neglect, and misappropriation of resident property.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review and interview the facility failed to ensure timely reporting of misappropriation to the Ohio Department of Health. This affected one resident (#180) of three residents (#33, #148, and #180) reviewed for abuse, neglect, and misappropriation of resident property. Findings Include: Review of the medical record for Resident #180 revealed an admission date of 01/11/22 and a discharge date of 04/01/23. Diagnoses included anemia, chronic obstructive pulmonary disease, vascular dementia, cocaine dependence with withdrawal, and insomnia. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #180 had impaired cognition and required limited assistance of one staff for bed mobility, transfers, and ambulation. Review of the nurse practitioner note dated 02/01/23 at 10:06 A.M. [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure treatments for skin impairments were provided as ordered for Resident #11. This affected one Resident (#11) of two residents reviewed for skin impairment. The facility census was 167.
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on observation, interview, and review of the manufacturer formulary, the facility failed to change an enteral tube feeding bag per manufacturer guidelines. This affected one Resident (Resident #91) of two residents reviewed for tube feeding. The facility census was 167.
- B
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Inspectors wroteBased on record review and staff interview the facility failed to ensure physicians orders were signed and dated. This affected five of 37 residents whose physician orders were reviewed, Residents #38, #47, #66, #80 and #93. The facility census was 167. Findings Include: 1. Medical record review revealed Resident #38 was admitted to the facility on [DATE] with diagnoses that included heart attack, urinary retention and malnutrition. Further review of the medical record revealed the monthly recapitulation of physician orders for March 2023 and February 2023 and telephone orders from 02/10/23 and 12/20/22 were not signed and dated by Resident #38's physician. 2. Medical record review revealed Resident #47 was admitted to the facility on [DATE] with diagnoses that included abnormal weight loss, pulmonary embolism and syphilis. [...]
Fire safety inspections
21 fire safety citations on file: 12 on June 2, 2026, 6 on June 6, 2024, 3 on April 27, 2023.
Every fire safety citation21 citations
- F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · June 2, 2026 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · June 2, 2026 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · June 2, 2026 · 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 · June 2, 2026 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · June 2, 2026 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · June 2, 2026 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · June 2, 2026 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · June 2, 2026 · Corrected (the home has a date of correction)
- E
Provide a written emergency evacuation plan.
K 711 · June 2, 2026 · 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 · June 2, 2026 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of highly flammable decorations.
K 753 · June 2, 2026 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · June 2, 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 · June 6, 2024 · Corrected (the home has a date of correction)
- F
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · June 6, 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 · June 6, 2024 · 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 · June 6, 2024 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · June 6, 2024 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · June 6, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 27, 2023 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · April 27, 2023 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 27, 2023 · Corrected (the home has a date of correction)