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 38 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
26D
7E
3F
Potential for minimal harm
0A
0B
1C
July 7, 2025Standard inspection, Complaint inspection · 16 citations
- G
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on record review, observation, policy review, and interview, the facility failed to provide evidence that enteral tube feedings were administered to prevent weight loss. This affected two residents (#57 and #60) out of three reviewed for tube feeding. The facility also failed to obtain weekly weights as ordered. This affected four residents (#11, #20, #57, and #60) out of six reviewed for nutrition. The facility also failed to provide adequate hydration to prevent dehydration. This affected one resident (#11) out of three reviewed for hydration. The facility census was 63. [...]
- E
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on record review and interview, the facility failed to ensure notice of transfer and bed hold notice was provided to the resident, and the discharge summary was completed. This affected six Residents #28, # 46, #55, #66 #118, and #119 of eight residents reviewed for hospitalization and discharge.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, interviews, review of resident council meeting minutes, review of dining council minutes, the facility failed to ensure palatable meals were being provided. This affected three residents (Resident #11, #30 and #45) and had the potential to affect 56 residents receiving food from the kitchen (except Residents # 6, #44, #51, #55, #57, #60, and #218 whom the facility identified as nothing by mouth). The facility census was 63.
- E
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, review of shower documentation and interviews, the facility failed to ensure accurate and complete bathing documentation was completed as required for four residents (Residents #5, #19, #33 and #57) of four residents reviewed for activities of daily living. The facility census was 63.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews, and record reviews the facility failed to follow enhanced barrier precautions as indicated during care for Resident #46, Resident #33, and #5. This affected one resident (#46) of three reviewed for pressure ulcers, one resident (#33) of three reviewed for catheter use, and one resident (#5) out of four reviewed for incontinence. The facility also failed to ensure staff performed hand hygiene during medication pass. This affected six residents (#23, #29, #48, #52, #61, and #130) out of eight observed for medication administration. The facility also failed to ensure staff followed contact precautions when entering Resident #12's room. This affected one resident (#12) of one reviewed for contact precautions. The facility census was 63.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wrote3. Review of the medical record for Resident #28 revealed an admission date of 05/02/24 with diagnoses including diabetes mellitus, hypertension, anxiety, depression, bipolar disorder, and chronic kidney disease. Review of the minimum data set (MDS) assessment dated [DATE] revealed Resident #28 was cognitively intact and required substantial or maximum assistance for activities of daily living (ADLs). On 06/24/25 at 3:01 P.M., an observation of Resident #28's room revealed Resident #28 was laying in bed calling for help and her call light was observed on the floor and out of reach. An interview at the time of observation with Certified Nursing Assistant (CNA) #27 verified Resident #28's call light was on the floor and out of reach. On 06/25/25 at 10:40 A.M., an observation revealed Resident #28 was lying in bed and the call light was not in reach. [...]
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on record review, observation, and interview, the facility failed to honor resident preferences as ordered by the physician. This affected one resident (#19) out of two reviewed for choices. The facility census was 63.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review, review of the facility's self-reported incident (SRI), and interview, the facility failed to conduct a thorough investigation of an allegation of abuse. This affected one resident (#32) out of four reviewed for abuse.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review, Resident Assessment Instrument (RAI) user manual review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate related to wounds. This affected one (Resident #46) of 21 residents reviewed for comprehensive assessments. The facility census was 63.
- D
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Inspectors wroteBased on record review and staff interview, the facility failed to ensure the appropriate Ohio Department of Mental Health and Addiction Services was timely notified of a significant change in a residents Pre-admission Screen (PASRR). The affected one (Resident #20) of three reviewed for PASRR status. The facility census was 63.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on record review, interview and facility policy review, the facility failed to ensure the baseline care plan included person-centered care that included goals to properly care for the resident's specific health and safety concerns and physician orders to prevent decline for Resident #118. This affected one (Resident #118) out of eight residents reviewed for baseline care planning. The facility census was 63.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on record review and interview, the facility failed to ensure medical records were accurate. This affected one (Resident #5) of 16 resident medical records reviewed. The facility census was 63.
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on record review, observations and interviews, the facility failed to provide meaningful resident-centered activities for Resident #57. This affected one (Resident #57) out of three residents reviewed for activities. The facility census was 63.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review, interview, policy review, and review of the employee handbook, the facility failed to ensure staff performed transfers in a safe manner per physician's orders and re-assess fall risk after a fall occurred. This affected one resident (#19) out of four reviewed for accident hazards. The facility census was 63.
- D
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Inspectors wroteBased on record review, interviews, and observations, the facility failed to ensure that colostomy care was provided as ordered and per resident's preference. This affected one resident (Resident #26) out of two residents reviewed for ostomy care.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on medical record review, interview, and facility policy review, the facility failed to ensure pain medications were administered timely to ensure effective pain management. This affected one resident (#120) out of eight residents reviewed for medication administration. The facility census was 63.
October 3, 2024Complaint inspection · 3 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 record review, observations and interviews the facility failed to ensure insulin was dated, labeled, and discarded properly. This affected six residents (#11, #12, #16, #30, #41 and Resident #53) of 12 residents reviewed for insulin storage.
- 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 5% (percent). A total of 24 medications were observed with two errors for a medication error rate of 8.33%. This finding affected two (Resident #39 and #41) of three residents observed for medication administration.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on record review, observation, interview and policy review the facility failed to maintain infection control standards when administering medications. This affected one (Resident #30) of three residents reviewed for infection control during medication administration.
October 24, 2023Complaint inspection · 4 citations
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation of video from camera in room and record review, the facility failed to ensure call lights were kept within reach and residents were able to use if desired. This affected Resident #152, one of three sampled residents. The census was 62.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure previously placed Fentanyl transdermal patches were removed prior to placing a new patch. This affected Resident #152, one of three sampled residents. The census was 62.
- 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, record review, and interview, the facility failed to ensure controlled substances (two Fentanyl transdermal patches) were disposed of properly after removal from resident. This affected Resident #152, one of three sampled residents. The total census was 62.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation of video from camera in room, record review, and interview, the facility failed to ensure infection control protocols were followed when providing resident care. This affected Resident #152. The total census was 62.
September 19, 2022Standard inspection · 10 citations
- F
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on interview, record review, and review of the facility policy, the facility failed to ensure State Tested Nursing Assistants (STNA) received 12 hours of inservices annually. This had the potential to affect all 75 of 75 residents residing in the facility.
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, facility policy review, and review of online resources for the Centers for Disease Control and Prevention (CDC), the facility failed to ensure staff wore personal protective equipment (PPE) as required when entering Resident #127 and #266's room who were under droplet precautions for COVID-19 observation. This had the potential to affect all 75 residents residing in the facility.
- E
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on record review and interview, the facility failed to ensure residents had accurate advance directives within the medical records. This affected four residents (Residents #14, #43, #59, and #62) of twelve residents reviewed for advanced directives.
- E
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on record review and interview, the facility failed to ensure meal intakes were monitored. This affected five residents (Resident #8, #14, #23, #61, and #62) of five residents reviewed for nutrition monitoring.
- 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 regular nail care was provided for Resident #23. This affected one resident (Resident #23) of three reviewed for activities of daily living care. The facility census was 75.
- D
Provide appropriate foot care.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure regular podiatry care was provided for Resident #23. This affected one resident (Resident #23) of three reviewed for activities of daily living care.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident #25's aerosol treatment was administered properly. This affected one resident (Resident #25) of out four residents observed for medication administration.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, record review, interview, and review of manufacture's guidelines, the facility failed to ensure a medication error rate of less than five percent (%). Four errors occurred within 26 opportunities for error resulting in a medication error rate of 15.38%. This affected two residents (Resident #25 and #31) of four residents observed during the mediation administration observation. The facility census was 75.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview and record review, the facility failed to document Resident #126's hospitalization. This affected one resident (Resident #126) of four residents reviewed for hospitalization.
- D
Implement a program that monitors antibiotic use.
Inspectors wroteBased on interview and record review, the facility failed to ensure the duration of Resident #18 antibiotic use was implemented and monitored properly. This affected one resident (Resident #18) out of three residents reviewed for urinary tract infections. The facility census was 75.
September 9, 2019Standard inspection · 5 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review and interview the facility failed to use alcohol-based hand sanitizer within dispensers mounted within resident care areas on the first and second facility resident care hallways. This had the potential to affect all 77 residents residing within the facility. The facility also failed to ensure Tuberculosis (TB) tests were completed or had the first step read before new employees started to work for five new employees (State Tested Nursing Assistant (STNA) #640, STNA #641, STNA #660, STNA #663, and STNA #697) out of ten employees reviewed. This had the potential to affect all 77 residents in the facility.
- 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 were given per physician's orders. This affected one resident (Resident #56) of two residents reviewed for non-pressure skin conditions. The facility census was 77.
- 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 record review, observation, and interview, the facility failed to ensure tube feed bags delivering enteral nutrition to residents were labeled with the formula, resident name, and time administered. This affected one resident (Resident #33) out of five residents identified by the facility as receiving tube feeds. The total census was 77.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on record review and interview the facility failed to prevent significant medication errors for two residents (#31 and #58) of five residents reviewed for medication administration. The census was 77.
- C
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on personnel record review, policy review, and interviews, the facility failed to implement their abuse policy and procedure in relation to employee reference checks prior to hire. This affected seven new employees out of ten employees reviewed (Licensed Nursing Home Administrator (LNHA), Maintenance Director (MD) #638, State Tested Nursing Assistant (STNA) #640, STNA #641, STNA #660, STNA #663, and STNA #697) and had the potential to affect all 77 residents in the facility.
Fire safety inspections
45 fire safety citations on file: 18 on July 7, 2025, 15 on September 19, 2022, 12 on September 9, 2019.
Every fire safety citation45 citations
- F
Conduct testing and exercise requirements.
E 39 · July 7, 2025 · 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 · July 7, 2025 · Corrected (the home has a date of correction)
- 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 · July 7, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · July 7, 2025 · Corrected (the home has a date of correction)
- F
Install an approved automatic sprinkler system.
K 351 · July 7, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 7, 2025 · Corrected (the home has a date of correction)
- F
Meet other general requirements that are deficient.
K 500 · July 7, 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 · July 7, 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 · July 7, 2025 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · July 7, 2025 · Corrected (the home has a date of correction)
- E
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · July 7, 2025 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · July 7, 2025 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · July 7, 2025 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · July 7, 2025 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · July 7, 2025 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · July 7, 2025 · 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 · July 7, 2025 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · July 7, 2025 · Corrected (the home has a date of correction)
- F
Address subsistence needs for staff and patients.
E 15 · September 19, 2022 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · September 19, 2022 · 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 · September 19, 2022 · 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 19, 2022 · Corrected (the home has a date of correction)
- F
Install properly constructed and protected linen or trash chutes.
K 541 · September 19, 2022 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · September 19, 2022 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · September 19, 2022 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · September 19, 2022 · Corrected (the home has a date of correction)
- E
Install a fire alarm system that can be heard throughout the facility.
K 341 · September 19, 2022 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · September 19, 2022 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · September 19, 2022 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · September 19, 2022 · Corrected (the home has a date of correction)
- E
Provide a written emergency evacuation plan.
K 711 · September 19, 2022 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · September 19, 2022 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · September 19, 2022 · 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 · September 9, 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 · September 9, 2019 · Corrected (the home has a date of correction)
- E
Properly provide smoke detection systems in areas open to corridors.
K 347 · September 9, 2019 · Waiver
- E
Install an approved automatic sprinkler system.
K 351 · September 9, 2019 · Corrected (the home has a date of correction)
- E
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · September 9, 2019 · Waiver
- E
Install corridor and hallway doors that block smoke.
K 363 · September 9, 2019 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · September 9, 2019 · Corrected (the home has a date of correction)
- C
Address subsistence needs for staff and patients.
E 15 · September 9, 2019 · Corrected (the home has a date of correction)
- C
Establish procedures for tracking staff and patients during an emergency.
E 18 · September 9, 2019 · Corrected (the home has a date of correction)
- C
Establish policies and procedures for volunteers.
E 24 · September 9, 2019 · Corrected (the home has a date of correction)
- C
Establish methods for sharing information.
E 33 · September 9, 2019 · Corrected (the home has a date of correction)
- C
Provide a means of sharing information on occupancy/needs.
E 34 · September 9, 2019 · Corrected (the home has a date of correction)