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 36 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
33D
2E
1F
Potential for minimal harm
0A
0B
0C
July 31, 2025Complaint inspection · 2 citations
- E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observations, resident interviews, staff interviews, an interview with the pest control provider, review of pest control invoices, and review of facility policy, the facility failed to maintain an effective pest control program. This affected three (Residents #62, #70, and #71) of six residents sampled for pest control and had the potential to affect all 21 residents living on the 400-Hall. The facility census was 84.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on medical record review, resident interview, staff interviews, and facility policy review, the facility failed to maintain communication for dialysis services and failed to ensure post-dialysis assessments were completed. This affected Resident #62, the only resident at the facility who received dialysis services. The facility census was 84.
June 3, 2025Complaint inspection · 2 citations
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, resident interview, staff interview, review of facility Self-Reported Incidents (SRIs) and review of the facility policy, the facility failed to ensure residents were free were free from abuse. This affected one (Resident (#17) of three residents reviewed for abuse. The facility census was 84 residents.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, resident interview, staff interview, review of facility Self-Reported Incidents (SRIs) and review of the facility policy, the facility failed to ensure allegations of abuse were reported immediately to the state agency. This affected one (Resident (#17) of three residents reviewed for abuse. The facility census was 84 residents.
February 25, 2025Standard inspection · 10 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on record review, observations, staff interviews, interview with the local Health Department staff, review of facility policies, review of the Center for Disease Control and Prevention (CDC) guidance, and review of Ohio Department of Health's (ODH) guidance for reporting infectious diseases, the facility failed to develop and implement effective infection control procedures which included when and to who potentially communicable diseases should be reported, failed to ensure the local Health Department was notified in a timely manner of a facility gastrointestinal illness (GI) outbreak and failed to track the residents and employees who developed GI related symptoms as part of their infection surveillance plan. This affected 13 Residents (#24, #22 #10, #35, #68, #66, #27, #02, #59, #07, #61, #237, #236, and #11) but had the potential to affect all residents at the facility. [...]
- 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 record review, staff interview, facility protocol, and review of facility policy, the facility failed to notify the physician or the non-physician practitioner (NPP) for residents with change in conditions. This affected three Residents (#05, #70, and #71) reviewed for changes in condition. The facility census was 88. Findings Included: 1) Review of medical record for Resident #05 revealed an admission date on 05/26/20. Diagnosis included obstructive hypertrophic cardiomyopathy, adult failure to thrive, Alzheimer's disease, chronic kidney disease stage two, orthostatic hypotension, essential hypertension, dementia, history of transient ischemic attack, and nonrheumatic aortic stenosis. Review of Resident #05's blood pressure monitoring revealed the following blood pressures documented: [...]
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on record review and staff interviews, the facility failed to issue an Advanced Beneficiary Notice (ABN) when a Notice of Medicare Non-Coverage (NOMNC) was issued to a resident under a Medicare stay and the resident did not discharge. This affected one Resident (#77) out of the three residents reviewed for ABN. The facility census was 88.
- 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 observation, staff interviews, record review, and review of a facility policy, the facility failed to maintain a clean and safe environment. This affected three Residents (#13, #64, and #08) out of three Residents reviewed for environment. The facility census was 88.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on record review and interview, the facility failed to complete a Pre admission Screening and Resident Review (PASRR) following a significant change in residents' condition. This affected two Residents (#10 and #41) out of two residents reviewed for a PASRR. The facility census was 88. Findings Include: 1) Review of the medical record for Resident #10 revealed she was admitted to 10/13/21. Her diagnoses included diabetes mellitus (DM), chronic obstructive pulmonary disease, hepatic failure, gastroparesis, contracture of muscle, schizophrenia, bipolar disorder, major depressive disorder, anxiety disorder, dementia, and pseudobulbar. Resident #10 was admitted to hospice care at the facility on 04/23/24. There was no correlating PASRR associated with the admission to Hospice. Review of the Minimum Data Set (MDS) dated [DATE], revealed Resident #10 is cognitively impaired. [...]
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on observation, staff interviews, and record review, the facility failed to ensure residents were provided with quarterly care conferences. This affected two Residents (#08 and #64) out of the two residents reviewed for care conference. The facility census was 88.
- 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, staff interview, and review of facility policy, the facility failed to ensure a resident's suprapubic urinary catheter was changed according to physician orders. This affected one Resident (#79) of the three residents review for foley catheters. The facility census was 88.
- 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 reviews, staff interviews, review of facility policy, and review of facility standing orders, the facility failed to ensure residents received medications as ordered. This affected one Resident (#05) of the five residents reviewed for medications. The facility census was 88.
- 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 staff interview, the facility failed to ensure residents' medications were stored properly. This affected one Resident (#26) out of the three residents reviewed. The facility census was 88.
- D
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observation, staff interview, record review and review of facility policy, the facility failed to maintain an effective pest control program. This affected Resident (#13) and had the potential to affect all 23 Residents living on the 200 unit. The facility census was 88.
June 11, 2024Complaint inspection · 2 citations
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on observation, interview ,record review, facilities investigation review, and policy review, revealed the facility failed to implement abuse policies to report allegations of resident abuse. This affected one resident, (Resident #25) of three residents reviewed for reporting abuse . The total facility census was 86. Findings Include: Record review of alleged victim Resident #25 revealed the resident was admitted to the attached skilled living facility on 11/19/20. The resident had a legal guardian and resided on the skilled living unit. Diagnoses for Resident #25 included age related physical debility, diabetes, atrial fibrillation, morbid obesity, dementia, psychosis, communication deficit, depressive disorder, muscle weakness, intellectual disabilities, and cerebrovascular disease. [...]
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on observation, interviews, record review, facility investigation report, and policy review, revealed the facility failed to report allegations of abuse. This affected one resident, (Resident #25) of three residents reviewed for reporting abuse. The total facility census was 86. Findings Include: Record review of alleged victim Resident #25 revealed the resident was admitted to the attached skilled living facility on 11/19/20. The resident had a legal guardian and resided on the skilled living unit. Diagnoses for Resident #25 included age related physical debility, diabetes, atrial fibrillation, morbid obesity, dementia, psychosis, communication deficit, depressive disorder, muscle weakness, intellectual disabilities, and cerebrovascular disease. [...]
March 4, 2024Complaint inspection · 2 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 record review, interview, and policy review, the facility failed to ensure a resident's representative was notified of medication changes. This affected one (Resident #84) of three residents reviewed for notifications. The facility census was 83.
- D
Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.
Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure the admission agreement was signed or explained to the resident or resident's representative. This affected one (Resident #84) of three residents reviewed for admission agreements. The facility census was 83.
January 12, 2022Standard inspection · 10 citations
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on medical record review, observation, staff and local health department personnel interview, review of the facility policy, and review of guidelines from the Centers for Disease Control and Prevention (CDC), the facility failed to properly isolate residents placed in transmission-based precautions (TBP) per CDC guidelines for Coronavirus Disease 2019 (COVID-19) infections to potentially prevent the spread of COVID-19. This affected four (#74, #68, #25, and #12) of eight residents reviewed for transmission-based precautions and infection control practices. The facility census was 81.
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on medical record review, staff interview and policy review, the facility failed to notify the resident and the Ombudsman of a transfer or discharge from the facility. This affected two (#79 and #330) out of two residents reviewed for discharge notification from the facility. The facility census was 81. Findings Include: Review of medical record for Resident #79 revealed he was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. Diagnosis included metabolic encephalopathy, acute neurologic, rhabdomyolysis, pleural effusion, dementia with behavioral disturbance, essential primary hypertension, diabetes mellitus 2, atrial fibrillation, congestive heart failure and history of malignant neoplasm of prostate. Review of the five day admission Minimum Data Set (MDS) assessment, dated 11/15/21 revealed Resident #79's cognition was not assessed. [...]
- D
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 medical record review, staff interview and facility policy review, the facility failed to notify residents of the facility bed hold policy prior to discharge from the facility. This affected two (#77, # 330) out of two residents reviewed for the bed hold policy. Facility census was 81.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on medical record review, staff interview and policy review, the facility failed to ensure a Pre-admission Screen and Resident Review (PASARR) was in place for Resident #47 and #48. This affected two (#47 and #48) out of two residents reviewed for PASARR status. The facility census was 81.
- 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 develop a comprehensive care plan to address resident care needs including medical skin condition, a resident's medical diagnosis and a resident's smoking. This affected three (#15, #61 and #47) of twenty-three residents reviewed for care plans. The facility census was 81.
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on medical record review, observation and staff interview, the facility failed to ensure palm protectors were placed on a resident with limited range of motion per the physician order. This affected one (#21) of two reviewed for range of motion. Facility census was 81.
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure the resident's laboratory (lab) work was completed per the physician orders. This affected one (#15) of six residents reviewed for unnecessary medication. The facility census was 81.
- D
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Inspectors wroteBased on medical record review, observation, staff and resident interview and policy review, the facility failed to ensure a residents meal was provided per the residents order and meal ticket. This affected one (#26) of three residents reviewed during the lunch observation. The census was 81.
- D
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Inspectors wroteBased on medical record review, observation, staff and resident interview, and policy review, the facility failed to ensure an assistive device was provided to a resident during a meal. This affected one (#26) of three resident's reviewed for adaptive equipment during the annual survey. Facility census was 81.
- D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on medical record review, observations, staff interview and facility policy review, the facility failed to provide a clean, comfortable, home-like environment. This affected one (#48) out of three residents reviewed for a clean environment. The facility census was 81.
May 16, 2019Standard inspection · 8 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 record review, policy review and staff interviews, the facility failed to ensure a physician received and responded to a resident medication not being available for administration. This involved one (#12) of three sampled residents reviewed for physician notice. Facility census was 79.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on record review and staff interview, the facility failed to ensure residents were issued Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) notices upon discharge from Medicare Part A Services with benefit days remaining when they continued to reside in the facility. This affected two (#67 and #68) of three residents reviewed for beneficiary protection notification. The facility census was 79.
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on observation, medical record review, review of facility submitted self reported incidents (SRIs), and review of facility policy, resident and staff interview, the facility failed to implement the facility policy on reporting allegations of verbal abuse. This affected three (#16, #21, and #80) of three residents reviewed for abuse. The census was 79.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on observation, medical record review, review of facility submitted self reported incidents (SRIs), and review of facility policy, resident and staff interview, the facility failed to report allegations of verbal abuse to the state agency. This affected three (#16, #21, and #80) of three residents reviewed for abuse. The census was 79.
- D
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 and staff interview, the facility failed to ensure bed hold notices were provided timely upon hospitalization. This affected two (#21 and #34) of four residents reviewed for hospitalization. The facility census was 79.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, record review, resident representative and staff interviews, the facility failed to ensure a resident received needed assistance with activities of daily living (ADLs). This affected one (#34) of four residents reviewed for ADLs. The facility census was 79.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review and staff interviews, the facility failed to ensure a resident received care and treatment to non-pressure skin condition. This affected one (#34) of two residents reviewed for non-pressure skin conditions. The facility census was 79.
- 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 and staff interview, the facility failed to ensure medications were administered in accordance to the physician's orders. This involved one (#12) of three sampled residents reviewed for medication availability. Facility census was 79.
Fire safety inspections
18 fire safety citations on file: 5 on February 25, 2025, 7 on January 12, 2022, 6 on May 16, 2019.
Every fire safety citation18 citations
- F
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
K 343 · February 25, 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 · February 25, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · February 25, 2025 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · February 25, 2025 · Corrected (the home has a date of correction)
- E
Have an alternate power supply for its alarm system.
K 344 · February 25, 2025 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · January 12, 2022 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · January 12, 2022 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 12, 2022 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · January 12, 2022 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · January 12, 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 · January 12, 2022 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · January 12, 2022 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · May 16, 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 · May 16, 2019 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · May 16, 2019 · Corrected (the home has a date of correction)
- F
Ensure proper usage of power strips and extension cords.
K 920 · May 16, 2019 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · May 16, 2019 · Corrected (the home has a date of correction)
- C
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · May 16, 2019 · Corrected (the home has a date of correction)