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 57 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
44D
8E
2F
Potential for minimal harm
0A
1B
0C
April 23, 2026Complaint inspection · 7 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 medical record review, interviews, review of Google Maps, and policy review, the facility failed to notify the physician and the Legal Guardian a resident was exiting the facility without supervision and left the facility property unsupervised. This affected one (#51) out of three residents reviewed for elopement. The facility census was 82.
- 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, staff interview, and review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure and admission [NAME] Data Set (MDS) 3.0 assesment was completed timely for one (#37) of four residents reviewed for MDS assessments. The facility census was 82.
- 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 ensure the baseline care plan included a resident's hearing status and interventions. This affected one (#85) of four residents reviewed for care plans. The facility census was 82.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review, interviews, review of Google Maps, and policy review, the facility failed to ensure a resident with directions from legal guardians not to leave the facility and residents with cognitive impairment did not leave the facility property unsupervised. This affected two (#51 and #84) of three residents reviewed for elopements. The facility census was 82.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on interview, record review and policy review, the facility failed to follow physician orders for non-pharmaceutical pain interventions for one (#86) of four residents reviewed for pain management. The facility census was 82.
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on interview, record review and policy review, the facility failed to meet the needs of residents with regard to the timeliness of reporting stat and critical laboratory (lab) results and have a lab policy. This affected two Residents (#85 and #87) of three residents reviewed for labs.
- 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, interviews, review of Google Maps, and policy review, the facility failed to document in the medical record when a resident was identified to have left the facility property unsupervised. This affected one (#51) of three residents reviewed for elopement. The facility census was 82.
April 2, 2026Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on medical record reviews, staff interviews, and policy review, the facility failed to complete comprehensive wound evaluations that included wound measurements or characteristics. This affected two (#09 and #85) residents out of the three residents reviewed for wound cares/services. The facility census was 81.
March 17, 2026Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on medical record review, staff and physician interviews and review of information from the American Diabetes Association, the facility failed to assess a resident and notify the physician of a residents elevated blood glucose levels. This affected one (#11) or three residents reviewed for blood sugar readings. The facility census was 75.
June 16, 2025Standard inspection, Complaint inspection · 14 citations
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on medical record review, observations, staff interviews, facility policy reviews, and review of the guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to thoroughly assess a resident's skin and failed to timely identify a resident's pressure ulcers until they reached an advanced stage. This resulted in Actual Harm to Resident #35, who developed pressure ulcers while in the facility, which were not identified until they had reached an advanced stage. Resident #35 was noted to have a reddened area on 01/14/25, according to shower sheets, but the area was not assessed, and interventions were not implemented until 01/16/25 when the pressure ulcer was identified as an unstageable pressure ulcer (sloughing and/or eschar) to the coccyx. This affected one (#35) of five residents reviewed for pressure ulcers. The facility census was 76.
- E
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 review of the medical record, interviews, and policy review, the facility failed to notify the physician for a change in condition. This affected four (#2, #3, #19, and #53) out of four of residents reviewed for a change in condition. The facility census was 76.
- E
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on medical record reviews, staff interviews, and policy reviews, the facility failed to complete a discharge summary or recapitulation of a resident's stay, failed to complete a bed hold notice when resident's were transferred to the hospital and failed to notify the Ombudsman of resident's discharges. This affected four (#15, #27, #75, and #134) out of four residents reviewed for discharges. The facility census was 76.
- 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, resident and staff interviews, and facility policy review, the facility failed to provide a homelike environment when meal trays were delivered to the residents with plasticware in place of silverware. This affected three Residents (#05, #67, and #129) out of three residents reviewed for home-like environment. The facility census was 76.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate coded. This affected one (#53) out of three residents reviewed for MDS accuracy. The facility census was 76.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on medical record review, observation, staff and resident interviews, and policy review, the facility failed to ensure a comprehensive skin assessment was completed upon admission. This affected one (#126) out of six residents reviewed for skin breakdown. The facility census was 76.
- 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, and facility policy review, the facility failed to ensure fall interventions were in place as care planned. This affected one (#31) out of one resident reviewed for falls. The facility census was 76.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wrote3. Review of the medical record for Resident #2 revealed an admission date of 02/28/25. Diagnoses included multiple sclerosis (MS), chronic obstructive pulmonary disease (COPD), and type II diabetes mellitus (DM II). Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12. This resident was assessed to require supervision with eating, dependent with toileting, bathing, dressing, and transfers. Review of the medical record for weights for Resident #2 revealed the following: - 02/28/25: 221.1 pounds - 03/01/25: 289.4 pounds - 03/02/25: 289.4 pounds - 03/11/25: 388.2 pounds - 03/18/25: 388.1 pounds - 03/25/25: 387.2 pounds - 03/26/25: 244 pounds - 04/01/25: 285.6 pounds - 04/04/25: 285.5 pounds - 05/05/25: 285.5 pounds - 06/11/25: [...]
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on review of the medical record, interviews, and policy review, the facility failed to timely implement appropriate interventions to manage a resident's pain. This affected one (#2) of five reviewed for pain management. The facility census was 76.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to assess a dialysis access site as per facility policy. This affected one (#132) out of one resident reviewed for dialysis. The facility census was 76.
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on record review, interview, and policy review, the facility failed to provide behavioral health services for Resident #14 who had diagnoses of mental disorders. This affected one (#14) of six residents reviewed for behavior management. The facility census was 76.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure medications were administered as ordered which resulted in a significant medication error. This affected one (#135) out of six residents reviewed for medication administration. The facility census was 76.
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on review of the medical record, interviews, observations, and policy review, the facility failed to follow up with dental services regarding a resident's missing dentures. This affected one (#2) of one resident reviewed for dental services. The facility census was 76.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on review of the medical record, observations, interviews, and policy review, the facility failed to maintain infection control measures during wound care and peri care. This affected three (#3, #35, and #67) of five reviewed for infection control. The facility census was 76.
December 30, 2024Complaint inspection · 1 citation
- 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, review of list of medications available in emergency box, staff interview, and policy review, the facility failed to administer a medication as per resident request and physician order. The affected one (#65) out of the three residents reviewed for medications administered as ordered. The facility census was 59.
November 18, 2024Complaint inspection · 1 citation
- 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 interview, resident interview, and policy review the facility failed to ensure a resident was provided with staff assistance at the bedside after toileting which resulted in a fall with injury. This resulted in actual harm when Resident #34 who required substantial/maximal assistance to transfer for toileting, did not have on gripper socks on her feet and was assisted off the bedside commode, became unsteady on her feet, was sat on the side of her bed, and the certified nursing assistant (CNA) left the resident alone and stepped out of the room to get additional staff assistance. The resident fell onto the floor face first when she was left on the side of the bed by herself resulting in a laceration that required the resident to get three stitches to her face. The affected one (Resident #34) of three residents reviewed for falls. The census was 83.
September 19, 2024Complaint inspection · 4 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 medical record reviews, staff interview, and policy review, the facility failed to notify resident representative of a resident's change in condition. This affected one (#33) resident out of three reviewed for changes in condition. The facility census was 63.
- 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 medical record reviews, staff interviews, and policy review, the facility failed to ensure safe and orderly discharges. This affected two (#67 and #68) out of four residents reviewed for discharges. The facility census was 63.
- D
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Inspectors wroteBased on medical record reviews, staff interviews, and policy review, the facility failed to ensure staff completed a recapitulation of a resident's stay upon discharge. This affected two (#66 and #70) out of four residents reviewed for discharges. The facility census was 63.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to properly assess a resident's skin breakdown at the time the area was first observed. Additionally, the facility failed to complete weekly monitoring of the wound and failed to complete treatments as ordered. This affected one (#33) out of three residents reviewed for wound care and services. The facility census was 63.
August 16, 2024Complaint inspection · 4 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to follow physician orders to obtain daily weights. This affected one (Resident #81) of three residents reviewed for nutrition. The facility census was 80 residents.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on record review, staff interview, and review of the facility policy, the facility failed to properly monitor resident weights and failed to implement nutritional recommendations to prevent weight loss. This affected one (Resident #83) of three residents reviewed for nutrition. The facility census was 80 residents.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure the medication error rate was less than five percent (%.) The facility medication error rate was 7.14% based on 28 medication opporunities and two medication errors. This affected two (Residents #22 and #68) of five residents reviewed for medication administration. The facility census was 80 residents.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on medical record review, observation, staff interview, and review of the facility policy, the facility failed to follow proper infection control practices when providing direct care for residents with physician's orders for enhanced barrier precautions (EBP). This affected two (Residents #9 and #55) residents of three reviewed for infection control. The facility census was 80 residents.
July 8, 2024Complaint inspection · 5 citations
- F
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on staff interview, record review, and policy review, the facility failed to ensure the resident's medication administration records (MAR) and treatment administration records (TAR) were available during disruption of internet services. This affected five (Residents #12, #13, #20, #26, and #61) of five residents reviewed for medical records and the potential to affect all 87 residents residing in the facility.
- E
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on medical record review, staff interviews, and policy review, the facility failed to ensure residents were free of any significant medication errors when the residents did not receive their medications as physician ordered when the electronic record was not available. This affected five (Residents #12, #13, #17, #26, and #61) of five residents reviewed for medication administration. The facility census was 87.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, staff interviews, medical record review, and policy review, the facility failed to implement Enhanced Barrier Precautions (EBP) for residents with chronic wounds and/or indwelling medical devices. This affected 11 (Residents #13, #18, #20, #23, #24, #25, #30, #36, #79, #82, and #88) of 23 residents reviewed for EBP. The facility census was 87.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, staff interview, record review, and policy review, the facility failed to timely identify and treat a resident's skin tear. This affected one (Resident #28) of three residents reviewed for wound care. The facility census was 87.
- 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 observations, staff interview, review of the facility policy, and record review, the facility failed to ensure residents received incontinence care in a timely manner. This affected one (Resident #61) of six residents reviewed for toileting assistance. The facility census was 87.
November 13, 2023Complaint inspection · 2 citations
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on medical record review, staff interview, and review of a facility policy, the facility failed to ensure residents received appropriate assistance with bathing. This affected three (#13, #16, and #23) of four residents reviewed for bathing assistance. The census was 54.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on medical record review and staff interview, the facility failed to obtain weekly weights as ordered. This affected one (#12) of three residents reviewed for nutrition. The census was 54.
September 13, 2023Complaint inspection, Infection control · 3 citations
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interview and policy review, the facility failed to ensure eye protection was worn into COVID-19 positive resident's rooms. This potentially could affect eight (#31, #12, #43, #34, #13, #1, #14, #30) of twelve residents who resided on the 200 hall and did not have COVID-19. The census was 48.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on medical record review, staff and resident interview and policy review, the facility failed to ensure bathing/showers was provided for residents who were dependent on staff for care. This affected two (#14 and #16) of three residents reviewed for bathing. The census was 48.
- D
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure referrals for outside services were made when requested by the family. This affected one (#16) of three residents reviewed for outside services. The census was 48.
March 2, 2023Standard inspection · 10 citations
- E
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 policy review, the facility failed to ensure timely completion of baseline care plans and failed to ensure residents and their representatives received a copy of the baseline care plan. This affected four (Residents #21, #50, #44, and #41) of nine residents reviewed for baseline care plans. The facility census was 44.
- E
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 record review and interview, the facility failed to ensure routine care conferences were held. This affected three (Residents #18, #41, and #42) of four residents reviewed for care planning. The facility census was 44.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview and policy review, the facility failed to ensure food was stored in a manner to prevent the potential spread of foodborne illness. This had the potential to affect 43 of 44 residents in the facility. The facility identified one resident (Resident #44) who did not receive food from the kitchen.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review, interview and policy review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded to reflect the resident's current health care status. This affected one (Resident #30) of five residents reviewed for accurate MDS assessments. The facility census was 44.
- 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 record review, interview and policy review, the facility failed to ensure the accuracy of care plans. This affected two (Residents #30 and #44) of 15 residents reviewed for care plans. The facility census was 44.
- 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, interview, and policy review, the facility failed to ensure a discharge summary was completed for a planned discharge. This affected one (Resident #59) of three residents reviewed for discharge. The facility census was 44.
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on record review, interview, and policy review, the facility failed to respond timely to recommendations from outside providers. This affected one (Resident #30) of 16 residents reviewed for ancillary services. The facility census was 44.
- 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, interview, and policy review, the facility failed to maintain complete, accurate documentation in the medical record. This affected one (Resident #57) of sixteen records reviewed for accuracy. The facility census was 44.
- D
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on record review, interview and policy review, the facility failed to ensure the Medical Director attended quality assurance performance improvement (QAPI) meetings. The facility census was 44.
- B
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on record review and interview, the failed to ensure a Minimum Data Set (MDS) assessment was completed and submitted to Centers of Medicare and Medicaid according to the Resident Assessment Instrument (RAI) Manual. This affected two (Residents #39 and #34) of five residents reviewed for MDS submissions. The facility census was 44.
December 28, 2019Standard inspection · 4 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on record review, observation, staff interview, review of the facility's policies, and Review of Centers for Disease Control and Prevention (CDC) toolkit assessment, the facility failed to properly cleanse the blood glucose monitoring machine. This affected Resident #7 during an observation of medication administration. This had the potential to affect Resident #85 and Resident #177 who were identified by the facility as having shared the blood glucose monitoring machine. In addition, the facility failed to ensure infection control monitoring was adequate to control the spread of communicable diseases. Also, the facility failed to ensure control measures and monitoring was in place for all potential hazardous conditions were Legionella had the potential to grow as identified by the facility. This had the potential to effect all 35 residents residing in the facility.
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on medical record review, review of the facility's Self-Reported Incidents, staff and resident interview and policy review, the facility failed to ensure the abuse policy was followed after an allegation of abuse was voiced by a resident. This affected one of one (#177) resident who triggered for abuse during the annual survey. The census was 35.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on medical record review, staff and resident interview, review of the facility's Self-Reported Incidents and policy review, the facility failed to ensure an allegation of abuse was reported to the State Survey Agency, the Ohio Department of Health. This affected one of one (#177) resident who made an allegation of abuse during the annual survey. The facility census was 35.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on medical record review, staff and resident interview, review of facility's investigation and policy review, the facility failed to ensure an allegation of abuse was thoroughly investigated. This affected one of one (#177) resident who made an allegation of abuse during the annual survey. The census was 35.
Fire safety inspections
19 fire safety citations on file: 4 on June 16, 2025, 6 on March 2, 2023, 9 on December 28, 2019.
Every fire safety citation19 citations
- F
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · June 16, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · June 16, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · June 16, 2025 · Corrected (the home has a date of correction)
- E
Install properly constructed and protected linen or trash chutes.
K 541 · June 16, 2025 · Corrected (the home has a date of correction)
- F
Conduct risk assessment and an All-Hazards approach.
E 6 · March 2, 2023 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · March 2, 2023 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 2, 2023 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · March 2, 2023 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · March 2, 2023 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · March 2, 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 28, 2019 · Corrected (the home has a date of correction)
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · December 28, 2019 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 28, 2019 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · December 28, 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 28, 2019 · Corrected (the home has a date of correction)
- E
Have horizontal exits used in accordance with safety requirements.
K 226 · December 28, 2019 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · December 28, 2019 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · December 28, 2019 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · December 28, 2019 · Corrected (the home has a date of correction)