The Vardell Report.Divine Rehabilitation and Nursing at Sylvania

Across 12 inspections from July 2021 to July 2026, state surveyors documented 93 findings at Divine Rehabilitation and Nursing at Sylvania; 93 have a recorded correction; CMS lists 4 enforcement actions in the window.

Inspections

12

2021–2026, complaint, standard and infection control

Findings

93

Deficiencies cited by state inspectors

Corrected

93

Of 93 findings, with a recorded correction date

Penalties

4

3 fines; payment not published, 1 closed

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

1. Jul 162026

   Complaint investigation

   10 findings

   • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level FNo actual harm, potential for moreCorrected Jul 28, 2026
   • F803Ensure 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.Level FNo actual harm, potential for moreCorrected Jul 28, 2026
   • F584Honor 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.Level ENo actual harm, potential for moreCorrected Jul 28, 2026
   • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Jul 28, 2026
   • F583Keep residents' personal and medical records private and confidential.Level DNo actual harm, potential for moreCorrected Jul 28, 2026
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Jul 28, 2026
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jul 28, 2026
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Jul 28, 2026
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Jul 28, 2026
   • F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected Jul 28, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

2. Jun 232025

   Complaint investigation

   1 finding

   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Jul 9, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

3. Mar 102025

   Standard health inspection

   24 findings

   The same visit included a complaint investigation.

   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level GActual harmCorrected Apr 1, 2025
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level ENo actual harm, potential for moreCorrected Apr 1, 2025
   • F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Level ENo actual harm, potential for moreCorrected Apr 1, 2025
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Apr 1, 2025
   • F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level ENo actual harm, potential for moreCorrected Apr 1, 2025
   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Apr 1, 2025
   • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Apr 1, 2025
   • F573Let each resident or the resident's legal representative access or purchase copies of all the resident's records.Level DNo actual harm, potential for moreCorrected Apr 1, 2025
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Apr 1, 2025
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Apr 1, 2025
   • F688Provide 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.Level DNo actual harm, potential for moreCorrected Apr 1, 2025
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Apr 1, 2025
   • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Apr 1, 2025
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Apr 1, 2025
   • F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Apr 1, 2025
   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Apr 1, 2025
   • F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level DNo actual harm, potential for moreCorrected Apr 1, 2025
   • F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Apr 1, 2025
   • F761Ensure 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.Level DNo actual harm, potential for moreCorrected Apr 1, 2025
   • F800Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.Level DNo actual harm, potential for moreCorrected Apr 1, 2025
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Apr 1, 2025
   • F909Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.Level DNo actual harm, potential for moreCorrected Apr 1, 2025
   • F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level BPotential for minimal harmCorrected Apr 1, 2025
   • F625Notify 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.Level BPotential for minimal harmCorrected Apr 1, 2025

   Enforcement Action

   Civil money penalty, $39,820 imposed March 10, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of March 10, 2025, the nearest before the penalty date.

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

4. Oct 232024

   Complaint investigation

   1 finding

   • F559Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.Level DNo actual harm, potential for moreCorrected Oct 24, 2024

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

5. Sep 262024

   Infection control inspection

   No findings

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

6. Apr 152024

   Complaint investigation

   2 findings

   • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level JImmediate jeopardyCorrected Apr 26, 2024
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Apr 26, 2024

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

7. Mar 212024

   Complaint investigation

   1 finding

   The same visit included an infection control inspection.

   • F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level DNo actual harm, potential for moreCorrected Apr 26, 2024

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

8. Mar 42024

   Complaint investigation

   3 findings

   • F678Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.Level JImmediate jeopardyCorrected Apr 26, 2024
   • F583Keep residents' personal and medical records private and confidential.Level DNo actual harm, potential for moreCorrected Apr 26, 2024
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Apr 26, 2024

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

9. Nov 162023

   Standard health inspection

   34 findings

   • F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Level FNo actual harm, potential for moreCorrected Jan 5, 2024
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Jan 5, 2024
   • F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.Level FNo actual harm, potential for moreCorrected Jan 5, 2024
   • F567Honor the resident's right to manage his or her financial affairs.Level ENo actual harm, potential for moreCorrected Jan 5, 2024
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level ENo actual harm, potential for moreCorrected Jan 5, 2024
   • F847Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.Level ENo actual harm, potential for moreCorrected Jan 5, 2024
   • F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level ENo actual harm, potential for moreCorrected Jan 5, 2024
   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Jan 5, 2024
   • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Jan 5, 2024
   • F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Level DNo actual harm, potential for moreCorrected Jan 5, 2024
   • F571Limit the charges against residents' personal funds for items or services for which payment is made under Medicare or Medicaid.Level DNo actual harm, potential for moreCorrected Jan 5, 2024
   • F578Honor 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.Level DNo actual harm, potential for moreCorrected Jan 5, 2024
   • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Jan 5, 2024
   • F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Level DNo actual harm, potential for moreCorrected Jan 5, 2024
   • F583Keep residents' personal and medical records private and confidential.Level DNo actual harm, potential for moreCorrected Jan 5, 2024
   • F584Honor 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.Level DNo actual harm, potential for moreCorrected Jan 5, 2024
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Jan 5, 2024
   • F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level DNo actual harm, potential for moreCorrected Jan 5, 2024
   • F625Notify 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.Level DNo actual harm, potential for moreCorrected Jan 5, 2024
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Jan 5, 2024
   • F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Level DNo actual harm, potential for moreCorrected Jan 5, 2024
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Jan 5, 2024
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Jan 5, 2024
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Jan 5, 2024
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jan 5, 2024
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Jan 5, 2024
   • F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected Jan 5, 2024
   • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Jan 5, 2024
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Jan 5, 2024
   • F710Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.Level DNo actual harm, potential for moreCorrected Jan 5, 2024
   • F712Ensure that the resident and his/her doctor meet face-to-face at all required visits.Level DNo actual harm, potential for moreCorrected Jan 5, 2024
   • F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Level DNo actual harm, potential for moreCorrected Jan 5, 2024
   • F761Ensure 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.Level DNo actual harm, potential for moreCorrected Jan 5, 2024
   • F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Level CPotential for minimal harmCorrected Jan 5, 2024

   Enforcement Action

   Civil money penalty, $16,746 imposed March 4, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of November 16, 2023, the nearest before the penalty date.

   Enforcement Action

   Civil money penalty, $75,033 imposed March 4, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of November 16, 2023, the nearest before the penalty date.

   Enforcement Action

   Denial of payment imposed March 4, 2024. Status: Closed, April 26, 2024. CMS does not tie a penalty to a survey; listed with the standard health inspection of November 16, 2023, the nearest before the penalty date.

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

10. Nov 62023

    Complaint investigation

    2 findings

    • F712Ensure that the resident and his/her doctor meet face-to-face at all required visits.Level DNo actual harm, potential for moreCorrected Jan 5, 2024
    • F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Level DNo actual harm, potential for moreCorrected Jan 5, 2024

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

11. Oct 102023

    Complaint investigation

    2 findings

    • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level GActual harmCorrected Nov 16, 2023
    • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Jan 5, 2024

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

12. Jul 152021

    Standard health inspection

    13 findings

    • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Sep 30, 2021
    • F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Level ENo actual harm, potential for moreCorrected Sep 30, 2021
    • F679Provide activities to meet all resident's needs.Level ENo actual harm, potential for moreCorrected Sep 30, 2021
    • F914Provide bedrooms that don't allow residents to see each other when privacy is needed.Level ENo actual harm, potential for moreCorrected Sep 30, 2021
    • F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level ENo actual harm, potential for moreCorrected Sep 30, 2021
    • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Sep 30, 2021
    • F569Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.Level DNo actual harm, potential for moreCorrected Sep 30, 2021
    • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Sep 30, 2021
    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Sep 30, 2021
    • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Sep 30, 2021
    • F700Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.Level DNo actual harm, potential for moreCorrected Sep 30, 2021
    • F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Sep 30, 2021
    • F732Post nurse staffing information every day.Level CPotential for minimal harmCorrected Sep 30, 2021

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

1. 1

   Accident Hazards and Supervision, Cited in Five Inspections

   Inspectors cited F689 in July 2021, November 2023, March 2025, June 2025 and July 2026. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   212323232424242424252526F689 across all 12 inspections, oldest to newest
2. 2

   Help With Daily Living, Cited in Four Inspections

   Inspectors cited F677 in October 2023, November 2023, March 2025 and July 2026. This citation covers help with bathing, dressing, eating and toileting for residents who cannot manage alone. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   212323232424242424252526F677 across all 12 inspections, oldest to newest
3. 3

   Needs and Preferences, Cited in Three Inspections

   Inspectors cited F558 in July 2021, November 2023 and March 2025. This citation covers whether the home reasonably accommodates each resident’s needs and preferences. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   212323232424242424252526F558 across all 12 inspections, oldest to newest
4. 4

   Citation F583, Cited in Three Inspections

   Inspectors cited F583 in November 2023, March 2024 and July 2026. The agency describes it this way: Keep residents' personal and medical records private and confidential. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   212323232424242424252526F583 across all 12 inspections, oldest to newest
5. 5

   Notice Before Transfer or Discharge, Cited in Three Inspections

   Inspectors cited F623 in November 2023, March 2024 and March 2025. This citation covers notice to the resident, their representative and the ombudsman before a transfer or discharge, including appeal rights. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   212323232424242424252526F623 across all 12 inspections, oldest to newest
6. 6

   Care Plan Timing and Review, Cited in Three Inspections

   Inspectors cited F657 in July 2021, November 2023 and March 2025. This citation covers whether care plans are written on time and revised by a team that includes the resident’s caregivers. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   212323232424242424252526F657 across all 12 inspections, oldest to newest
7. 7

   Quality of Care, Cited in Three Inspections

   Inspectors cited F684 in November 2023, March 2025 and July 2026. This citation covers whether residents receive the treatment their orders, preferences and goals call for. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   212323232424242424252526F684 across all 12 inspections, oldest to newest
8. 8

   Pressure Injury Care, Cited in Three Inspections

   Inspectors cited F686 in April 2024, March 2025 and July 2026. This citation covers how the home prevents and treats pressure injuries (bedsores). The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   212323232424242424252526F686 across all 12 inspections, oldest to newest
9. 9

   Respiratory Care, Cited in Three Inspections

   Inspectors cited F695 in July 2021, November 2023 and March 2025. This citation covers oxygen, breathing treatments and other respiratory care. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   212323232424242424252526F695 across all 12 inspections, oldest to newest
10. 10

    Kitchen and Food Safety, Cited in Three Inspections

    Inspectors cited F812 in July 2021, November 2023 and March 2025. This citation covers how food is stored, prepared and served. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    212323232424242424252526F812 across all 12 inspections, oldest to newest
11. 11

    Citation F921, Cited in Three Inspections

    Inspectors cited F921 in July 2021, November 2023 and March 2025. The agency describes it this way: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    212323232424242424252526F921 across all 12 inspections, oldest to newest
12. 12

    Dignity and Resident Rights, Cited in Two Inspections

    Inspectors cited F550 in November 2023 and March 2025. This citation covers residents’ right to dignity, to make their own choices and to communicate. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    212323232424242424252526F550 across all 12 inspections, oldest to newest
13. 13

    Citation F561, Cited in Two Inspections

    Inspectors cited F561 in July 2021 and November 2023. The agency describes it this way: Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    212323232424242424252526F561 across all 12 inspections, oldest to newest
14. 14

    A Clean, Homelike Setting, Cited in Two Inspections

    Inspectors cited F584 in November 2023 and July 2026. This citation covers whether rooms and shared spaces are kept safe, clean, comfortable and homelike. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    212323232424242424252526F584 across all 12 inspections, oldest to newest
15. 15

    Protection From Abuse and Neglect, Cited in Two Inspections

    Inspectors cited F600 in October 2023 and April 2024. This citation covers whether residents are protected from abuse and neglect by anyone. The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    212323232424242424252526F600 across all 12 inspections, oldest to newest
16. 16

    Investigating Alleged Violations, Cited in Two Inspections

    Inspectors cited F610 in November 2023 and March 2024. This citation covers how the home responds to and investigates an allegation of abuse, neglect or mistreatment. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    212323232424242424252526F610 across all 12 inspections, oldest to newest
17. 17

    Citation F625, Cited in Two Inspections

    Inspectors cited F625 in November 2023 and March 2025. The agency describes it this way: 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. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    212323232424242424252526F625 across all 12 inspections, oldest to newest
18. 18

    Continence and Catheter Care, Cited in Two Inspections

    Inspectors cited F690 in November 2023 and July 2026. This citation covers continence care, catheter care and preventing urinary tract infections. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    212323232424242424252526F690 across all 12 inspections, oldest to newest
19. 19

    Nutrition and Hydration, Cited in Two Inspections

    Inspectors cited F692 in November 2023 and March 2025. This citation covers whether residents get enough food and fluids to stay healthy. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    212323232424242424252526F692 across all 12 inspections, oldest to newest
20. 20

    Citation F712, Cited in Two Inspections

    Inspectors cited F712 in November 2023 and November 2023. The agency describes it this way: Ensure that the resident and his/her doctor meet face-to-face at all required visits. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    212323232424242424252526F712 across all 12 inspections, oldest to newest
21. 21

    Psychotropic Medications, Cited in Two Inspections

    Inspectors cited F758 in November 2023 and March 2025. This citation covers how psychotropic drugs are used, including dose reductions and limits on as-needed orders. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    212323232424242424252526F758 across all 12 inspections, oldest to newest
22. 22

    Medication Error Rate, Cited in Two Inspections

    Inspectors cited F759 in July 2021 and March 2025. This citation covers whether medication errors stayed under 5 percent when inspectors watched medications being given. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    212323232424242424252526F759 across all 12 inspections, oldest to newest
23. 23

    Medication Labeling and Storage, Cited in Two Inspections

    Inspectors cited F761 in November 2023 and March 2025. This citation covers how drugs are labeled and kept locked, including controlled drugs. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    212323232424242424252526F761 across all 12 inspections, oldest to newest
24. 24

    Infection Control, Cited in Two Inspections

    Inspectors cited F880 in March 2025 and July 2026. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    212323232424242424252526F880 across all 12 inspections, oldest to newest

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

1. 01

   What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?

   Accident Hazards and Supervision: cited in five inspections, most seriously at level D.

2. 02

   How long do residents usually wait for help with bathing, dressing or the bathroom, and how is that tracked?

   Help With Daily Living: cited in four inspections, most seriously at level D.

3. 03

   How do you adjust rooms, schedules and routines to a resident’s needs and preferences?

   Needs and Preferences: cited in three inspections, most seriously at level D.

4. 04

   What changed after F583 was cited, and how do you check it now?

   Citation F583: cited in three inspections, most seriously at level D.

5. 05

   When do you transfer or discharge a resident, and how much notice do families get?

   Notice Before Transfer or Discharge: cited in three inspections, most seriously at level D.

6. 06

   How often are care plans revised, and who takes part in the review?

   Care Plan Timing and Review: cited in three inspections, most seriously at level E.

7. 07

   How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?

   Quality of Care: cited in three inspections, most seriously at level D.

8. 08

   How often are residents checked for pressure injuries and repositioned, and who is responsible for it?

   Pressure Injury Care: cited in three inspections, most seriously at level G.

9. 09

   Who manages oxygen and breathing treatments on each shift, and how is the equipment checked?

   Respiratory Care: cited in three inspections, most seriously at level D.

10. 10

    May we see the kitchen, and what do your own sanitation checks look like week to week?

    Kitchen and Food Safety: cited in three inspections, most seriously at level F.

11. 11

    What changed after F921 was cited, and how do you check it now?

    Citation F921: cited in three inspections, most seriously at level E.

12. 12

    How do staff learn each resident’s preferences, and how is a complaint about dignity handled?

    Dignity and Resident Rights: cited in two inspections, most seriously at level D.

13. 13

    What changed after F561 was cited, and how do you check it now?

    Citation F561: cited in two inspections, most seriously at level E.

14. 14

    What was done about the cleanliness citation, and how are rooms and shared spaces checked now?

    A Clean, Homelike Setting: cited in two inspections, most seriously at level E.

15. 15

    What happened after the abuse or neglect citation, and what changed in training or supervision?

    Protection From Abuse and Neglect: cited in two inspections, most seriously at level J.

16. 16

    When an allegation is made, who investigates it, and how are residents protected in the meantime?

    Investigating Alleged Violations: cited in two inspections, most seriously at level D.

17. 17

    What changed after F625 was cited, and how do you check it now?

    Citation F625: cited in two inspections, most seriously at level D.

18. 18

    How is continence care scheduled, and how do you prevent urinary infections?

    Continence and Catheter Care: cited in two inspections, most seriously at level D.

19. 19

    How are weight and fluid intake tracked, and what happens when a resident starts losing weight?

    Nutrition and Hydration: cited in two inspections, most seriously at level D.

20. 20

    What changed after F712 was cited, and how do you check it now?

    Citation F712: cited in two inspections, most seriously at level D.

21. 21

    How many residents take psychotropic medications, and how often are doses reviewed for reduction?

    Psychotropic Medications: cited in two inspections, most seriously at level E.

22. 22

    How are medication passes checked, and what happens when an error is found?

    Medication Error Rate: cited in two inspections, most seriously at level D.

23. 23

    How are medications stored and secured, and who checks the medication carts?

    Medication Labeling and Storage: cited in two inspections, most seriously at level D.

24. 24

    Who leads infection control here, and how often are hand-hygiene and isolation practices audited?

    Infection Control: cited in two inspections, most seriously at level E.

25. 25

    How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?

    Insufficient nursing staff was cited in July 2026.

26. 26

    What led to the 2025 fine, and has it been paid?

    A $39,820 civil money penalty was imposed March 10, 2025. CMS publishes the fine, not whether it has been paid. The record holds four enforcement actions in the window.

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Ohio state survey agency.

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Ohio state survey agency

  Inspection Jul 15, 2021 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Ohio state survey agency

  Inspection Oct 10, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Ohio state survey agency

  Inspection Nov 6, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Ohio state survey agency

  Inspection Nov 16, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Ohio state survey agency

  Inspection Mar 4, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Ohio state survey agency

  Inspection Mar 21, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Ohio state survey agency

  Inspection Apr 15, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Ohio state survey agency

  Inspection Sep 26, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Ohio state survey agency

  Inspection Oct 23, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Ohio state survey agency

  Inspection Mar 10, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Ohio state survey agency

  Inspection Jun 23, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Ohio state survey agency

  Inspection Jul 16, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Penalties, Provider Data Catalog

  Centers for Medicare & Medicaid Services

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗
• Provider Information, Provider Data Catalog

  Centers for Medicare & Medicaid Services · 365898

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.