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 31 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
5E
6F
Potential for minimal harm
0A
3B
1C
August 28, 2025Standard inspection · 1 citation
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure the right to privacy and confidential medical records for 2 (Resident #45 and Resident #59) of 67 facility residents. Specifically, observations revealed the computer screen on two medications carts was left visible in a facility hallway, while Resident #45 and Resident #59's identification and personal health information (PHI) was displayed.
July 9, 2024Complaint inspection · 1 citation
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, staff interviews and policy review, the facility failed to ensure staff smoked only in designated areas of the facility in accordance with the facilities smoking policy. This affected one (Resident #58) of three reviewed for oxygen usage. The facility census was 62.
June 6, 2024Complaint inspection · 1 citation
- 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 observations, staff interview interview, and review of the facility policy, the facility failed to ensure there were no expired tube feed formula bottles stored in the medication rooms and central supply room. The facility identified one resident (#26) who received Glucerna 1.5 (a specialized tube feed formula) and no residents currently who received Nephro 1.8 (a specialized tube feed formula). The facility identified 11 residents who receive tube feed formula. The facility census was 63.
December 6, 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 medical record review, review of the State of Ohio Board of Pharmacy Terminal Distributor Licensure of Prescriber Practices, review of facility policy, staff interview, and interview with contracted entity provider representative, the facility failed to ensure a contracted entity had appropriate State of Ohio required credentials for provision of services for residents. This affected four (#01, #09, #11, and #12) of the four residents reviewed for medications administered by a contracted ancillary provider. This also affected two additional current Residents (#03 and #19) and 16 discharged Residents (#02, #04, #05, #06, #07, #08, #10, #13, #14, #15, #16, #17, #18, #20, #21, and #22) for total of 22 residents. The facility census was 46.
- 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 medical record review, review of the State of Ohio Board of Pharmacy Terminal Distributor Licensure of Prescriber Practices, staff interview and contracted entity provider representative interview, 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 affected four (#01, #09, #11, and #12) of the four residents 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 wroteBased on medical record review, review of the State of Ohio Board of Pharmacy Terminal Distributor Licensure of Prescriber Practices, review of facility policy, and interview the facility failed to ensure a contracted entity had appropriate State of Ohio required credentials for provision of services for residents. This affected four (#01, #09, #11, and #12) of the four residents reviewed for medications administered by a contracted ancillary provider. This also affected two additional current Residents (#03 and #19) and 16 discharged Residents (#02, #04, #05, #06, #07, #08, #10, #13, #14, #15, #16, #17, #18, #20, #21, and #22) for total of 22 residents. The facility census was 46.
June 9, 2022Standard inspection · 11 citations
- F
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, observation, staff interview, and review of facility policy, the facility failed to timely discard expired medications. This affected two (#195 and #15) residents with expired medications observed in the medication carts and had the potential to affect all 41 residents residing in the facility who could potentially receive expired stock medications. The census was 41.
- F
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Inspectors wroteBased on observations, staff interviews, review of a meal spreadsheet and policy review, the facility failed to provide qualified staff to ensure meals were provided as ordered by the physician. This had the potential to affect all 41 residents residing in the facility. The facility census was 41.
- F
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Inspectors wroteBased on observations, staff and resident interviews, review of a spreadsheet and policy review, the facility failed to ensure sufficient and trained dietary staff to meet residents' dietary needs. This had the potential to affect all 41 residents residing in the facility who received meals from the kitchen. The facility census was 41.
- 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, staff interview, review of the dish machine log and policy review the facility failed to label foods, sanitize dishes and store ice machine scoop in a sanitary manner. This had the potential to affect all 41 residents residing in the facility who received food from the kitchen. The facility census was 41.
- E
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, observation and staff , the facility failed to provide puree and mechanical soft diets as planned by a Registered Dietitian. This had the potential to affect two (#19 and #245) residents with orders for a puree diet, and six (#8, #10, #24, #41, #44 and #195) residents with orders for a mechanical soft diet. The facility census was 41.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on record review, observation, staff interview, and review of manufacturers guidelines, the facility failed to properly clean and sanitize blood glucose meters after use. This affected four (#22, #19, #7, and #14) of four residents observed for blood glucose monitoring. The census was 41.
- 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, observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure residents were dressed in a dignified manner. This affected one (Resident #195) of 12 residents reviewed for dignity. The census was 41.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on record review, observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure residents were bathed according to their preference. This affected one resident (#7) of 12 residents reviewed for bathing preferences. The census was 41.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record review, observations and staff interview, the facility failed to implement a physician ordered intervention for a speciality cushion to a residents wheelchair to promote healing of a pressure ulcer. This affected one (#44) of three residents reviewed for pressure ulcers. The facility census was 41.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wrote2. Record review revealed Resident #44 was admitted on [DATE] with diagnosis of hemorrhage of cerebrum, loss of consciousness unspecified, pneumonia, dementia, and chronic heart failure. Resident #44 received hospice services. Review of the Significant Change Minimum Data Set, (MDS), dated [DATE] revealed Resident #44 was cognitively impaired and required extensive assistance of two staff for care. Review of current physician orders revealed continuous oxygen at 3.5 milliliters via nasal cannula and change oxygen tubing every week on Sunday night shift and as needed. Observation on 05/31 22 at 12:24 P.M. and on 06/01/22 at 2:49 P.M. revealed Resident #44 was receiving oxygen via nasal cannula and the oxygen tubing was not dated. Interview on 06/01/22 at 2:50 P.M. [...]
- 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, observation, staff interview, and review of facility policy, the facility failed to ensure proper documentation of administration of controlled substances and accounting for controlled substance medications. This affected two (#15 and #20) of nine facility-identified residents with controlled substances stored on the Primrose Unit medication cart. The facility also failed to administer a residents medications (Ativan and Lyrica) as ordered. This affected one (#195) out of three residents reviewed for medication administration. The census was 41.
April 11, 2019Standard inspection · 14 citations
- 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 date foods stored in the refrigerator and failed to dispose of outdated foods in the kitchen. This had the potential to affect all 33 residents in the facility receiving meals from the kitchen.
- F
Keep all essential equipment working safely.
Inspectors wroteBased on observation and staff interview, the facility failed maintain the stove and dish washer in safe operating conditions. This had the potential to affect all 33 resident receiving meals from 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, observation and interviews, the facility failed to honor a resident's dignity when she was not provided incontinence care in a timely manner during night shift and she was left sopping wet in her bed. This affected one (Resident #9) of 16 residents reviewed during the annual survey for dignity issues. The resident census was 33.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and interview, the facility failed to accurately code resident's status on the Minimum Data Set (MDS) Assessments. This affected two (Residents #36 and #27) of 16 residents sampled. The resident census was 33.
- 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, staff interview and policy review, the facility failed to initiate a baseline care plan within 48 hours of admission. This affected one (Resident #33) of 13 residents baseline care plans reviewed. The facility census was 33.
- 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 complete comprehensive care plans to address resident needs. This affected two (Residents #9 and #33) of 13 residents reviewed for comprehensive care plans. The facility census was 33.
- D
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Inspectors wroteBased on record review and interview, the facility failed ensure discharge records contained a recapitulation of the resident's stay, a final summary of resident's status, and a reconciliation of all pre- and post- discharge medications. This affected two (Residents #37 and #36) of four residents reviewed for discharge. The facility census was 33.
- 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 provide a resident with incontinence care to maintain personal hygiene. This affected one (Resident #9) of 16 residents sampled. The resident census was 33.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review and staff interview, the facility failed to provide laboratory testing to monitor the use of medications. This affected one (Resident #17) of five residents reviewed for unnecessary medications. The resident census was 33.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on review of monitoring measures, interview and policy review, the facility failed to have any water monitoring for Legionella; failed to provide a functional sink where staff and residents could wash their hands in the Main Shower Room. This occurred in one (Main Shower Room) of two shower rooms used by 16 residents (Residents #12, #8, #13, #25, #30, #35, 328, #23, #34, #4, #16, #9, #10, #19, #22 and #17); and failed to administer Tuberculosis (TB) testing in accordance with facility policy. This involved six employees (Maintenance Director #2, Registered Nurse (RN) #21, Licensed Social Worker (LSW) #6, Housekeeper #34, the Director of Nursing (DON) and State Tested Nurse Aide (STNA) #4) of eleven personnel files reviewed. This had the potential to affect all residents residing in the facility. Facility census was 33.
- C
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on record review, interview and policy review, the facility failed to ensure reference checks were obtained on employees prior to hire. This affected two (Dietary Manager #5 and Registered Nurse #21) of eight employees hired since 01/01/19. This had the potential to affect all 33 residents in the facility.
- B
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on record review and interview, the facility failed to provide Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) letters to residents discharged from skilled care to nursing care. This affected three (Residents #13, #26 and #31) of three residents reviewed for Beneficiary Protection Notification. The facility census was 33.
- B
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 record review, staff interview and policy review, the facility failed to provide residents, resident representatives, and/or the local Ombudsman the required notification of transfer when the residents were sent out to the hospital. This affected two (Residents #26 and #33) of three residents reviewed for hospitalization. The facility census was 33.
- B
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on record review, interview and policy review, the facility failed to provide residents and/or resident representatives the required bed hold notices when residents were transferred to the hospital. This affected two (Residents #26 and #33) of three residents reviewed for hospitalization. The facility census was 33.
Fire safety inspections
28 fire safety citations on file: 3 on August 28, 2025, 12 on June 9, 2022, 13 on April 11, 2019.
Every fire safety citation28 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 28, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 28, 2025 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · August 28, 2025 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · June 9, 2022 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · June 9, 2022 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 9, 2022 · 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 · June 9, 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 · June 9, 2022 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · June 9, 2022 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · June 9, 2022 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · June 9, 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 · June 9, 2022 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · June 9, 2022 · Corrected (the home has a date of correction)
- E
Have an enclosure around a vertical opening shaft.
K 311 · June 9, 2022 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · June 9, 2022 · Corrected (the home has a date of correction)
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · April 11, 2019 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · April 11, 2019 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 11, 2019 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 11, 2019 · Corrected (the home has a date of correction)
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · April 11, 2019 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · April 11, 2019 · 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 · April 11, 2019 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · April 11, 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 · April 11, 2019 · Corrected (the home has a date of correction)
- E
Install a fire alarm system that can be heard throughout the facility.
K 341 · April 11, 2019 · Corrected (the home has a date of correction)
- E
Have an alternate power supply for its alarm system.
K 344 · April 11, 2019 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · April 11, 2019 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · April 11, 2019 · Corrected (the home has a date of correction)