The most recent inspection on file for Buckeye Forest at Fairfield Assisted Living took place on April 22, 2026. Across the 32 inspections published by the Ohio Department of Health, surveyors cited 44 deficiencies.
A deficiency is a rule the surveyor found the facility was not meeting. Ohio inspects against two rule books at once, so most findings carry a federal code and an Ohio code for the same problem; each is counted once here, the way the state counts it. Correction dates are the state's confirmation that the issue was fixed.
This report reproduces what Ohio publishes and nothing else. Of the 32 inspections listed, the state publishes the surveyor's written findings for 13; for the other 19 it publishes only the date, the type of visit and the number of deficiencies - 19 of which found none.
Facility Details
Inspections
32 on file · 44 deficienciesApril 22, 2026Complaint survey · listed in Ohio's index; no findings report publishedNo deficiencies▼
March 26, 2026Complaint survey · listed in Ohio's index; no findings report publishedNo deficiencies▼
February 18, 2026Complaint survey4 deficiencies▼
R-0311Initial assessment time frame▼
Based on medical record review and staff interview, the facility failed to ensure initial assessment was completed at the time of admission. This affected one (#116) of three residents reviewed for admission process. The facility census was 115.
Findings include
Review of the medical record for Resident #116 revealed an admission on 10/28/25 with diagnoses including generalized edema, chronic obstructive pulmonary disease, asthma, bipolar disorder with behaviors and viral hepatitis C.
Review of the initial assessment tab in the electronic health record revealed an initial assessment was not completed on admission.
Interview on 02/04/25 at 10:10 A.M. with Assisted Living Director #01 confirmed Resident #116's initial admission assessment was not completed and should have been.
This violation is based on incidental findings discovered during the course of this complaint investigation.
R-0338Administered meds - MD orders▼
Based on medical record review and staff interview, the facility failed to ensure prescribed medications were available for administration. This affected one (#47) of five residents reviewed for narcotic pain medications availability. The facility census was 115.
Findings include:
Medical record review for Resident #47 revealed an admission on 11/12/21 with diagnoses including but not limited to low back pain and disc degeneration.
Review of the self administration of medication assessments for Resident #47 revealed the facility staff provided the monitoring and administration of narcotic medications.
Review of the physician orders for Resident #47 revealed an order dated oxycodone 5 milligram tablet every four hours as needed for pain dated 01/18/23.
Review of the medication administration record for Resident #47 for the month of September 2025 revealed the resident did not receive any oxycodone 5 mg tablets on 09/01/25 to 09/02/25.
Review of the progress notes for Resident #47 dated 08/29/25 at 4:01 P.M. that nurse faxed oxycodone prescription to the physician. Resident #47 and case manager were notified.
Review of the electronic medication administration record revealed Resident #47 received oxycodone 5 mg tablet on 08/31/25 at 5:49 P.M. and the next dose was not recorded until 09/04/25 at 2:00 A.M.
Interview on 02/04/26 at 12:37 P.M. with Director of Nursing (DON) verified the facility did not have the medication available for Resident #47 if requested.
Interview on 02/05/26 at 1:16 P.M. with Physician #12 verified he did not have any documentation related to the lack of medication (oxycodone) for Resident #47. Additionally, Physician #12 confirmed that he was not contacted for any additional prescription for Resident #47.
This violation represents non-compliance investigated under Complaint Numbers OH00169446 and OH00169214.
R-0339Administered meds - given only to and as prescribed▼
Based on medical record review, observation, staff interview and policy review, the facility failed to document all narcotic medications at the time of administration. This affected three (#100, #107 and #47) of five residents reviewed for medication administration documentation. The facility census was 115.
Findings included.
1. Review of the medical record for Resident #47 revealed an admission on 11/12/21 with diagnoses including but not limited to low back pain and disc degeneration.
Review of the self administration of medication assessments for Resident #47 revealed the facility staff provided the monitoring and administration of narcotic medications.
Review of the physician orders for Resident #47 revealed an order dated oxycodone 5 milligram tablet every four hours as needed for pain dated 01/18/23.
Review of the medication administration record for Resident #47 for the month of January 2025 revealed the resident received 73 tablets.
Review of the controlled drug administration report for the month of January 2026 revealed Resident #47 received 211 tablets.
Interview on 02/04/26 at 12:37 P.M. with the Director of Nursing (DON) verified the facility did not accurately document the administration of all oxycodone medication on the medication administration record for Resident #47 and they should have.
2. Review of the medical record for Resident #107 revealed an admission on 4/14/25 with diagnoses including heart failure, hypertension, arthropathy and cellulitis.
Review of the self administration of medication assessments for Resident #107 dated 07/24/25 revealed the facility staff provided the monitoring and administration of narcotic medications.
Review of the physician orders for Resident #107 revealed an order dated 11/15/25 for hydrocodone- acetaminophen oral tablet 5-325 mg give two tablets every six hours as needed for pain.
Review of the medication administration record for Resident #107 for the month of January 2025 revealed the resident received 51 tablets.
Review of the controlled drug administration report for the month of January 2026 revealed Resident #47 received 55 tablets.
Interview on 02/04/26 at 12:37 P.M. with the DON verified the facility did not accurately document the administration of all hydrocodone- acetaminophen oral tablet medication on the medication administration record for Resident #107 and they should have.
3. Medical record review for Resident #100 revealed an admission on 07/08/22 with diagnoses including but not limited to chronic obstructive pulmonary disease and type two diabetes without complications.
Review of the physicians order for Resident #100 revealed an order dated 07/27/23 for Pregabalin (controlled substance) Oral Capsule 50 mg give 1 capsule by mouth three times a day for neuropathy.
Observation on 02/04/26 at 11:45 A.M. of Licensed Practical Nurse (LPN) #21 removed one tablet of Pregabalin (controlled substance) Oral Capsule 50 mg from the medication cart locked narcotic drawer. LPN #21 knocked and entered the room for Resident #100 and determined the resident was not in the room. LPN #21 placed the medication in the top drawer of the medication cart and pushed the cart to the next room. LPN #21 located Resident #100, retrieved the cup of medication from the top drawer of the medication cart and administered the Pregabalin (controlled substance) Oral Capsule 50 mg) but did not sign off the narcotic sheet and placed the empty narcotic card in the narcotic binder and closed the binder.
Interview on 02/04/26 at 12:00 P.M. with LPN #21 and DON verified the LPN did not sign off the narcotic medication when administered. Further interview with DON stated the LPN should have signed the medication off on the controlled drug administration record at the time of the administration. The DON verified LPN #21 should not store medication that has been prepared for administration in the top drawer of the medication cart and should be destroyed if not used.
Review of the facility policy titled Administration Procedures for all Medications dated 08/2020 revealed the facility failed to implement the policy. The policy states all medication should be document administration and document the administration on the controlled substance sheet.
This violation is based on incidental findings discovered during the course of this complaint investigation.
R-0397Hand hygiene; hand washing and use of alcohol-based products▼
Based on medical record review, observations, staff interview and policy review the facility failed to ensure facility staff used appropriate infection control measures when preparing and administering medications. This affected four (#100, #94, #54 and #78) out of five residents reviewed for medication and infection control. The facility census was 115.
Findings include:
1. Medical record review for Resident #100 revealed an admission on 07/08/22 with diagnoses including but not limited to chronic obstructive pulmonary disease and type two diabetes without complications.
Review of the physicians' order for Resident #100 revealed an order dated 07/27/23 for Pregabalin (controlled substance) oral capsule 50 milligrams (mg), give one capsule by mouth three times a day for neuropathy.
Observation on 02/04/26 at 11:45 A.M. of Licensed Practical Nurse (LPN) #21 retrieve medication cart keys from uniform pocket and unlock the medication cart. LPN #21 turned keys over in her hands to retrieve a different key and unlock the narcotic compartment. LPN #21 located the medication card and pushed the tablet thru the back of the medication card using her finger and placing the oral pregabalin tablet into her hand. LPN #21 dropped the tablet into a plastic administration cup. LPN #21 locked the medication cart and knocked on Resident #100's door. LPN #21 entered the room after turning the door handle for Resident #100's room and determined the resident was not in the room. LPN #21 unlocked the medication cart and placed the medication in the top drawer, closed the drawer and pushed the cart to the next room.
2. Medical record review for Resident #94 revealed an admission on 12/21/23 with diagnoses including but not limited to hemiplegia and hemiparesis following a stroke.
Review of the physicians' order for Resident #94 revealed an order dated 11/18/25 for Loratadine oral tablet 10 mg, give 10 mg by mouth in the afternoon for allergies and an order dated 12/23/23 for Gabapentin oral capsule 400 mg, give 800 mg by mouth four times a day for neuropathy.
Observation on 02/04/26 at 11:52 A.M. of LPN #21 retrieved medication cart keys from uniform pocket and unlocked the medication cart. LPN #21 located the gabapentin medication card after touching all the cards in the section for Resident #94. LPN #21 then pushed the tablets through the back of the medication card with the tablet landing into her bare hand. LPN #21 then slid the gabapentin tablet into a medication administration cup from the palm of her hand. LPN #21 then opened the top drawer of the medication cart and retrieved a multidose bottle of loratadine 10 mg, unscrewing the lid and shaking the bottle until one tablet fell into her open bare palm of her hand. LPN #21 then tilted her hand pouring the loratadine tablet into the plastic administration cup. LPN #21 then handled the water pitcher handle and poured water into a plastic drinking cup. LPN #21 knocked and entered the room for Resident #100 and administered the medication to the resident. LPN #21 pushed the medication cart to the next room.
3. Medical record review for Resident #54 revealed an admission on 06/06/25 with diagnoses including but not limited to hemiplegia and hemiparesis following a stroke, alcohol dependence, depression and opioid dependency.
Review of the physician's order for Resident #54 revealed an order dated 09/02/25 for baclofen tablet 10 mg one tablet by mouth three times a day for pain.
Observation on 02/04/25 at 11:54 A.M. of LPN #21 revealed LPN #21 retrieved medication cart keys from uniform pocket and unlocked the medication cart. LPN #21 located the baclofen medication card after touching all the cards for the resident in the specified section. LPN #21 pushed the tablet through the back of the medication card with the tablet landing into her bare hand. LPN #21 then slid the baclofen tablet into a medication administration cup. LPN #21 then knocked on Resident #54 room door. Resident #54 did not answer, and LPN #21 unlocked the room door using the keypad and called out to the resident. Resident #54 was not in his room. LPN #21 returned to the medication cart and opened the top drawer of the medication cart using keys from her pocket. LPN #21 sat the medication cup in the top drawer and shut the drawer and pushed the medication cart to the next room.
4. Medical record review for Resident #78 revealed an admission on 09/30/18 with diagnoses of Parkinson's disease, anemia, and chronic pain.
Review of the physicians' orders for Resident #78 revealed an order for Tylenol Extra Strength oral tablet 500 mg, give 2 tablet by mouth every six hours as needed for pain dated 01/30/26.
Observation on 02/04/26 at 11:57 A.M. of LPN #21 retrieved medication cart keys from uniform pocket and unlocked the medication cart. LPN #21 located the multidose bottle of Tylenol and shook the bottle until two tablets landed into her bare hand. LPN #21 then slid the Tylenol tablets into a medication administration cup. LPN #21 then placed a plastic cup on the medication cart and picked up the pitcher containing the water pouring it into the glass. LPN #21 then locked the medication cart and knocked on Resident #78's room door. Resident #78 answered and LPN #21 handed the medication to the resident for consumption.
Interview on 02/04/26 at 12:04 P.M. with LPN #21 verified she did not perform hand hygiene prior to administering the medications. LPN #21 verified she handled the medications prior to administration for Resident #100, #94, #78, and #54. LPN #21 verified she touched objects between the preparation of medication and the administration of the medication and did not follow infection control policy.
Interview on 02/04/26 at 12:08 P.M. with the Director of Nursing (DON) verified the staff should not touch the medication prior to administering it to the resident's.
Review of the facility policy titled Administration Procedures for all Medications dated 08/2020 revealed the facility failed to implement the policy. The policy states to cleanse hands using Antimicrobial soap and water or facility provided hand sanitizer before beginning a med pass, before handling medication and before contact with a resident.
This violation is based on incidental findings discovered during the course of this complaint investigation.
September 11, 2025Licensure survey16 deficiencies▼
R-0092Time frame for criminal records check, termination▼
Based on record review and staff interview, the facility failed to ensure background checks were received for all new employees. This had the potential to affect all of the residents residing in the facility. The facility census was 104 residents.
Findings include:
Review of the personnel file for Licensed Practical Nurse (LPN) #96 revealed a hire date of 07/29/25. There was no evidence that a completed background check had been received for LPN #96.
Interview on 09/10/25 at 2:41 P.M. with Human Resources Director (HRD) #220 verified the background check had not yet been received for LPN #96.
R-0305Policy provision, including advanced directives/DNR, skilled nursing, special care unit▼
Based on review of the facility policy and documents and staff interview, the facility failed to have a special care unit policy which contained the required elements. This had the potential to affect nine residents (#3, #4, #5, #6, #7, #8, #9, #10, and #11) that resided on the memory care unit. The facility census was 104 residents.
Findings include:
Review of the facility policy titled Assisted Living Memory Care Unit dated February 2024 revealed the policy did not include information regarding transfer and discharge and the cost of services.
Review of the facility policy titled Enhancing Independence undated revealed the policy did not include information regarding transfer and discharge and the cost of services.
Review of hte facility document titled Memory Care Checklist undated revealed the policy did not include information regarding transfer and discharge and the cost of services.
Interview on 09/09/25 at 5:33 P.M. with the Director of Nursing (DON) verified the facility lacked a memory care policy with all the required elements.
R-0313Annual health assessment content▼
Based on medical record review and staff interview, the facility failed to ensure annual functional assessments were completed. This affected two (Residents #3 and #56) out of eight residents reviewed for assessments. The facility census was 104.
Findings include:
1. Review of the medical record for Resident #3 revealed an admission date of 06/11/24 with diagnoses including angina pectoris, anxiety disorder, hypertensive heart disease, delusional disorders, and mild cognitive impairment of uncertain or unknown etiology. Resident #3's record did not include a recent annual functional assessment.
2. Review of the medical record for Resident #56 revealed an admission date of 11/07/19 with diagnoses including atrial fibrillation, anemia, central pain syndrome, hyperlipidemia, and hypertension. Resident #56's record did not include a recent annual functional assessment
Interview on 09/11/25 at 10:54 A.M. with the Director of Nursing (DON) verified Residents #3 and #56's records did not include recent up-to-date annual functional assessments.
This violation represents noncompliance investigated under Complaint Number OH00168136.
R-0392Establish/implement written infection control P/P; infection prevention and control program and designee requirements▼
Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure staff implemented appropriate infection control techniques during resident care. This affected two (Residents #10 and #14) of three residents reviewed for infection control. The facility census was 104 residents.
Findings include:
1. Review of the medical record for Resident #10 revealed an admission date of 05/30/25 with diagnoses including type two diabetes mellitus, alcoholic cirrhosis of liver, bipolar disorder, major depressive disorder, congestive heart failure, anxiety disorder, and dementia.
Review of the active physician's orders for Resident #10 revealed an order for a wound treatment to the left lateral posterior foot to clean the wound with normal saline, pat dry, apply Santyl to wound bed, cover with bordered gauze and wrap with gauze daily.
Observation on 09/10/25 at 9:56 A.M. of wound care for Resident #10 per Licensed Practical Nurse (LPN) #24 revealed the nurse donned clean gloves and then removed the gloves and put them in a basket with the wound care supplies. LPN #24 then washed her hands threw away the gloves that were in the basket and put on clean gloves. LPN #24 removed the old dressing from Resident #10's foot, moved the trashcan closer, measured the wound, cleansed the wound, applied Santyl to wound bed, covered the wound with bordered gauze, and then wrapped Resident #10's foot with gauze without changing gloves or performing hand hygiene.
Interview on 09/10/25 at 10:10 A.M. with LPN #24 confirmed she had not changed gloves after removing the old wound dressing.
Review of the facility policy titled Wound Care dated August 2024 revealed staff were to remove a wound dressing and then discard it before practicing hand hygiene and putting on clean gloves.
2. Review of the medical record for Resident #14 revealed an admission date of 08/16/23 with diagnoses including chronic obstructive pulmonary disease, cognitive communication deficit, schizophrenia, anemia, chronic kidney disease, and chronic atrial fibrillation.
Observation on 09/10/25 at 8:23 A.M. of medication adminstration for Resident #14 per LPN #96 revealed the nurse administered medications to the resident #14 while wearing gloves. While wearing gloves, LPN #96 touched the laptop on the medication cart, silenced a phone, and then punched out medications while wearing the same gloves.
Interview on 09/10/25 at 8:26 A.M. with LPN #96 verified she had been wearing gloves and touched multiple objects during medication administration for Resident #14.
Review of the facility policy titled Administering Medications dated 04/28/25 revealed staff should follow established facility infection control procedures for the administration of medications.
R-0393Tuberculosis control plan and risk assessment▼
Based on record review, staff interview, review of Tuberculosis (TB) policy and TB risk assessment, the facility failed to adhere to the policy related to staff TB screenings. This had the potential to affect all residents residing in the facility. The facility census was 104 residents.
Findings include:
1. Review of the personnel file for Hospitality Aide (HA) #76 revealed a hire date of 02/21/24. Further review of the personnel file for HA #76 revealed no evidence of annual TB screening.
2. Review of the personnel file for HA #44 revealed a hire date of 05/16/24. Further review of the personnel file for HA #44 revealed no evidence of annual TB screening.
Interview on 09/10/25 at 2:41 P.M. with Human Resources Director (HRD) #220 confirmed the facility did not have evidence of TB screenings for HA #44 and HA #76.
Review of the TB risk assessment worksheet completed for 2025 revealed staff would be screened yearly for TB.
Review of the facility policy titled Tuberculosis Infection Control Program dated January 2012 revealed the program included an annual risk assessment to provide TB risk classification, controls established in accordance with the current risk classification, and screening and surveillance of residents and employees as appropriate for the current TB risk classification.
R-0559Procure, store, prepare, distribute and serve foods▼
Based on observation, staff interview, and review of the facility policy, the facility failed to ensure food was properly stored, prepared, and served in a manner to prevent food-borne illness. This had the potential to affect all of the residents residing in the facility. The facility census was 104 residents.
Findings include:
1. Observation on 09/08/25 at 9:41 A.M. of the kitchen revealed the dishwasher was operating as a chemical sanitizing dishwasher. The sticker on the dishwasher indicated the final rinse temperature should be 120 degrees Fahrenheit (F). The dishwasher was used several times and the gauges on top of the dishwasher never moved to indicate what the temperature was.
Interview on 09/08/25 at 9:44 A.M. with Dietary Aide (DA) #136 verified the gauges to the dishwasher were not working at the time of the observation.
Review of the facility policy titled General Guidelines for Food Safety dated 2021 revealed staff should be sure the wash and rinse temperatures were appropriate for the dishwasher.
2. Observation on 09/08/25 at 9:45 A.M. in the kitchen revealed multiple packages of frozen chicken were being thawed in a sink with no water running.
Interview on 09/08/25 at 9:46 A.M. with Cook #110 verified the frozen chicken was being thawed in the sink without water running on it.
Review of the facility policy titled General Guidelines for Food Safety dated 2021 revealed safe thawing practices included completely submerging the item in clean running water that was running fast enough to agitate and cause loose ice particles to float off.
3. Observation on 09/08/25 at 10:16 A.M. of the walk-in refrigerator revealed it contained the following opened and undated items: a plastic bag of parmesan cheese, wrapped sliced American cheese, a package of Swiss cheese slices, a container of barbecue sauce, a jar of tartar sauce, a tub of ricotta cheese.
Interview on 09/08/25 at 10:16 A.M. with Dietary Director (DD) #146 confirmed the items in the refrigerator were not marked with a date.
Review of the facility policy titled General Food Preparation and Handling undated revealed staff should label and date foods and put them away promptly.
4. Observation on 09/10/25 at 11:30 A.M. revealed Cook #110 had several thermometers and attempted to obtain meal temperatures prior to lunch being served.
Observation on 09/10/25 at 11:50 A.M. revealed DD #146 also attempted to obtain food temperatures. DD #146 tried several thermometers without success but was eventually able to get a digital thermometer to function. However, the thermometer was stuck around 30 degrees F, which required staff to subtract from the temperatures obtained.
Interview on 09/10/25 at 11:51 A.M. with DD #146 confirmed the facility should have a working digital thermometer in order to check food temperatures at each meal.
Review of the facility policy titled General Guidelines for Food Safety dated 2021 revealed staff should check food temperatures correctly.
This violation is a recite to the complaint survey completed 08/28/25.
R-0564Kitchen and dining areas clean and sanitary; transporting meals; garbage▼
Based on observations and staff interview, the facility failed to maintain a clean and sanitary kitchen. This had the potential to affect all of the residents residing in the facility. The facility census was 104 residents.
Findings include:
1. Observation on 09/08/25 at 9:57 A.M. of the three-compartment sink revealed there was food and trash in the sanitizing compartment of the sink.
Interview on 09/08/25 at 9:59 A.M. with Dietary Director (DD) #146 verified there was food and trash in the sink at the time of the observation. DD #146 stated there had been an issue with the sink backing up which caused the food and trash to flow into the sanitizing compartment.
2. Observation on 09/08/25 at 10:11 A.M. of the kitchen revealed there were four trash cans without lids.
Interview on 09/08/25 at 10:11 A.M. with DD #146 verified the garbage cans did not have lids/
3. Observation on 09/08/25 at 10:13 A.M. of the kitchen revealed the wall near the garbage cans and garbage disposal had multiple black spots on the wall as well as gnats flying around the area.
Interview on 09/08/25 at 10:13 A.M. with DD #146 confirmed the presence of the black spots and gnats near the garbage cans.
4. Observation on 09/08/25 at 10:16 A.M. of the walk-in refrigerator revealed there was a wet sludgelike substance with a black tint on the floor of the refrigerator.
Interview on 09/08/25 at 10:17 A.M. with DD #146 verfiied the presence of a wet sludgelike substance on the floor of the walk in refrigerator. .
This violation is a recite to the complaint survey completed 08/28/25.
R-0608Clear and unobstructed paths of egress; propping open of doors▼
Based on observation and staff interview, the facility failed to ensure doors were not propped open and failed to ensure doors were equipped with appropriate hardware to allow for proper and safe functioning of the doors. This had the potential to affect all of the residents residing in the facility. The facility census was 104 residents.
Findings include:
1.Observation on 09/08/25 at 9:32 A.M. revealed the doors from kitchen to the dining room were propped open. Additionally, it was found that the doors were missing the latching hardware as designed. Further observation found that the kitchen door to the service hall was also propped open and had no latching hardware as designed.
Interview on 09/09/25 at 3:30 P.M. with the Administrator confirmed the findings.
2.Observation on 09/08/25 at 11:28 A.M. revealed the cross-corridor doors by the dining room on the memory care unit did not have the self-closer installed on the door one of the door leaves. The door closest to a resident room did not have the self-closing device attached. Further observation found the doors were integrated with the fire alarm system. This would not allow for the doors to operate as designed and required by code.
Interview on 09/09/25 at 3:30 P.M. with the Administrator confirmed the findings.
3.Observation on 09/08/25 at 11:38 A.M. revealed the door to a resident's room on the memory care unit was not closing and latching as designed. Observation noted cloth materials around the door that would not allow the door to close and latch. Additionally, it was noted that there were corridor doors throughout the facility that were missing doorknobs and latching hardware. This would not resist the passage of smoke in the event of an emergency.
Interview on 09/09/25 at 3:30 P.M. with the Administrator confirmed the findings.
4.Observation on 09/10/25 at 8:26 A.M. on the second floor revealed the door to the laundry room was propped open.
Interview on 09/10/25 at 8:26 A.M. with Hospitality Aide (HA) #50 verified the door was propped open.
5.Observation on 09/10/25 at 8:46 A.M. on the third floor revealed the door to the laundry room was propped open.
Interview on 09/10/25 at 8:46 A.M. with Activities Director (AD) #108 verified the laundry room door was propped open.
6.Observation on 09/10/25 at 8:57 A.M. on the fourth floor revealed the door to the laundry room was propped open,.
Interview on 09/10/25 at 8:57 A.M. with AD #108 verified the laundry room door was propped open.
This violation represents noncompliance investigated under Complaint Number OH00168136.
R-0615Fire drill requirements▼
Based on record review, staff interview, and policy review, the facility failed to ensure residents capable of self-evacuation were evacuated to safe areas in at least two fire drills per year on each shift. This had the potential to affect all of the residents residing in the facility. The facility census was 104 residents.
Findings include:
Review of the fire drills completed from 09/01/24 to 09/09/25 revealed no evidence of evacuations of residents capable of self-evacuation.
Interview on 09/09/25 at 3:26 P.M. with Maintenance Director (MD) #184 verified the facility had not ensured residents capable of self-evacuation were evacuated during fire drills.
Review of the facility policy titled Fire Drill Policy dated March 2019 revealed fire drills would include practice in building evacuation procedures.
R-0616Disaster drill requirements▼
Based on record review, staff interview, and policy review, the facility failed to conduct at least two disaster drills. This had the potential to affect all of the residents residing in the facility. The facility census was 104 residents.
Findings include:
Review of the disaster drills from 09/01/24 to 09/09/25 revealed only one disaster drill, a tornado drill, was completed.
Interview on 09/09/25 at 3:26 P.M. with Maintenance Director (MD) #184 verified the facility only completed one disaster drill.
Review of the facility policy titled Emergency Drills and Exercises reviewed September 2019 revealed the facility would conduct drills throughout the year testing the emergency preparedness plans and procedures.
R-0619Written record of drills and evaluation▼
Based on record review and staff interview, the facility failed to maintain documentation related to drills that included all required elements. This had the potential to affect all of the residents residing in the facility. The facility census was 104 residents.
Findings include:
Review of the fire drills completed from 09/01/24 to 09/09/25 revealed the drill reports lacked information related to the number of individuals evacuated, the total time for evacuation, and the weather conditions during the evacuation.
Interview on 09/09/25 at 3:26 P.M. with Maintenance Director (MD) #184 verified the drill reports lacked information related to evacuations.
R-0623Annual staff training on fire prevention▼
Based on record review and staff interview, the facility failed to ensure all staff completed annual fire prevention training. This had the potential to affect all of the residents residing in the facility. The facility census was 104 residents .
Findings include:
Review of the fire safety documentation revealed no evidence staff had completed annual fire prevention training from an approved source.
Interview on 09/10/25 at 12:16 P.M. with the Administrator verified the facility had no evidence that staff completed annual fire prevention training.
R-0627Smoking requirements, including electronic smoking device, and vapor products▼
Based on observation, staff interview, and review of facility Self-Reported Incidents (SRIs), the facility failed to ensure signs were posted near oxygen storage, failed to ensure cigarette butts were disposed of in proper receptacles, and failed to ensure residents did not smoke in nondesignated areas. This had the potential to affect all of the residents residing in the facility. The facility census was 104 residents.
Findings include:
1. Observation on 09/08/25 at 11:49 A.M. revealed the storage room on C Hall of the third floor had multiple oxygen tanks being stored without a sign on the door indicating no-smoking was permitted.
Observation on 09/08/25 at 11:59 A.M. revealed the storage room on the A Hall of the third floor had multiple oxygen tanks being stored without a sign on the door indicating no smoking was permitted.
Interviews on 09/08/25 at 3:48 P.M. and 3:49 P.M. with Maintenance Director (MD) #184 verified there were no signs on the doors where the oxygen tanks were being stored that indicated no smoking was permitted.
2.Observation on 09/08/25 at 12:30 P.M. of the smoking area revealed there was a red metal self-closing trash can with a plastic bag liner and there was combustible trash inside the can and liner.
Interview on 09/08/25 at 12:31 P.M with the Administrator confirmed the metal trash can in the smoking area had a plastic liner which contained combustible trash.
3.Observation on 09/08/25 at 3:55 P.M. revealed there was an odor of cigarette smoke on the fourth floor in D Hall and MD #184 knocked on the door. Resident #84 was smoking inside the room and the resident stated she did not want to go outside to smoke at the time.
Interview 09/08/25 at 3:55 P.M with MD #184 confirmed Resident #184 was smoking inside her room which was not permitted. MD #184 confirmed residents were only permitted to smoke in the designated smoking area.
4. Observation on 09/08/25 at 4:03 P.M. revealed there were plastic receptables for cigarette butts in the smoking area.
Interview on 09/08/25 at 4:04 P.M. with MD #184 confirmed the receptacles for cigarette butts in the smoking area were made of plastic.
5. Observation on 09/08/25 at 4:04 P.M. revealed there were multiple cigarette butts in the mulch in the smoking area.
Interview on 09/08/25 at 4:05 P.M. with MD#184 verified there were cigarette butts in the mulch in the smoking area.
Interview on 09/11/25 at 2:21 P.M. with the Administrator confirmed the facility had a fire which had occurred in the early morning in the smoking area on 08/25/25. The Administrator confirmed the facility found a cigarette butt which had been disposed of in a flower bed in the smoking area which the facility's investigation determined was the source of the fire.
Review of the facility SRI created on 08/25/25 revealed a cigarette butt was disposed of in a flower bed in the smoking area, which caused a piece of wood to catch on fire. The SRI indicated the fire was immediately doused. Per the SRI, there were no witnesses.
This violation represents noncompliance investigated under Complaint Number OH00168225 and Complaint Number OH00168182 and Complaint Number 168136.
R-0645Resident-activated call system▼
Based on medical record review, observation, and staff interview, the facility failed to ensure residents had functioning call lights that could not be deactivated from any location except from where the call was initiated, unless the staff was able to communicate with the resident. This affected two (Residents #63 and #88) and had the potential to affect all of the other residents residing in the facility. The facility census was 104 residents.
Findings include:
1. Review of the medical record for Resident #63 revealed an admission date of 08/24/23 with a diagnosis of multiple sclerosis.
Observation on 09/10/25 at 10:59 A.M. with Hospitality Aide (HA) #86 revealed the aide activated the call pendant for Resident #63 and was able to turn off the call light at the monitoring station without interacting with Resident #63.
Interview on 09/10/25 at 11:00 A.M. with HA #86 verified Resident #63's call light could be deactivated without going to the resident's room or communicating with the residents.
2. Review of the medical record for Resident #88 revealed an admission date of 01/23/24 with diagnoses including hypertension, muscular dystrophy, hyperlipidemia, and depression.
Observation on 09/10/25 at 10:23 A.M. revealed the call pendant in Resident #88's room was activated.
Interview on 09/10/25 at 10:57 A.M. with HA #86 confirmed an alert was sent to a tablet when Resident #88's call light was pressed. HA #86 stated the tablet needed to be charged and she had not received an alert that Resident #88's call light had been activated.
Interview on 09/10/25 at 1:53 P.M. with HA #86 confirmed the tablet was functioning properly and an alert indicated Resident #88's call light had been activated three hours and 39 minutes prior to the interview.
This violation represents noncompliance investigated under Complaint Number OH00168155.
R-0674Floors in good repair▼
Based on observation, staff interview, and policy review, the facility failed to ensure all floors were in good repair. This had the potential to affect all of the residents residing in the facility. The facility census was 104 residents.
Findings include:
Observation on 09/08/25 at 12:02 P.M. revealed the carpet on the A Hall of the third floor was wrinkled, which caused the carpet to be uneven. There was also duct tape between the transition of the carpet between the A Hall and the carpet in the common area.
Interview on 09/08/25 at 3:49 P.M. with Maintenance Director (MD) #184 verified the wrinkled carpet and duct tape.
Review of the facility policy titled Quality of Life - Homelike Environment dated May 2017 revealed residents were to be provided with a safe, clean, comfortable and homelike environment.
This violation represents noncompliance investigated under Complaint Number OH00168136.
R-0710Safe and clean environment▼
Based on observation, staff interview, and review of the facility policy, the facility failed to provide a safe and clean-living environment. This had the potential to affect all of the residents residing in the facility. The facility census was 104 residents
Findings include:
1. Observation on 09/08/25 at 11:21 A.M. of the second floor B Hall revealed the heating/cooling unit had multiple areas of black spots on the vent.
Interview on 09/08/25 at 3:33 P.M. with Maintenance Director (MD) #184 verified the black spots on the vent.
2. Observation on 09/08/25 at 11:29 A.M. of the dining room in the memory care unit revealed a piece of drywall missing and an electrical box with wires exposed.
Interview on 09/08/25 at 3:37 P.M. with MD #184 verified the piece of missing drywall and the exposed wires.
3. Observation on 09/08/25 at 11:40 A.M. of the memory care unit revealed a room at the end of the hall near the stairwell that was unlocked and being used to store various furniture, trash, and broken items. The room was missing a cooling/heating unit on the wall, which left a large vent to the outside exposed.
Interview on 09/08/25 at 3:42 P.M. with MD #184 verified the door was unlocked with trash, broken items, and the large vent to the outside exposed.
4. Observation on 09/10/25 at 2:13 P.M. of Resident #56's room revealed there were faded black spots on the wall.
Interview on 09/10/25 at 2:13 P.M. with MD #184 confimred he believed the spots on Resident #56's wall were from moisture and were related to mildew.
Review of the facility policy titled Quality of Life - Homelike Environment dated May 2017, revealed residents would be provided with a safe, clean, comfortable and homelike environment.
This violation represents noncompliance investigated under Complaint Number OH00168136 and Complaint Number OH00168141.
August 28, 2025Complaint survey2 deficiencies▼
R-0559Procure, store, prepare, distribute and serve foods▼
Based on observation, staff interview, and review of facility policy, the facility failed to store food in a sanitary manner. This had the potential to affect all of the residents residing in the facility. The facility census was 108 residents.
Findings include:
Observation on 08/28/25 at 11:36 A.M. with Dietary Manager (DM) #3 of the dry storage area revealed the following items: a one gallon container of vanilla flavoring opened 03/09/24 with an expiration date of 02/10/24, one bag of opened undated mini marshmallows with an expiration date of June 2025, a bag of open undated salad croutons, a bag of open undated turkey gravy mix, a bag of open undated frosting mix, a bag of open to air undated dry spaghetti noodles, a container of uncovered mashed potato granules, a bag of open undated chicken soup mix.
Interview on 08/28/25 at 11:38 A.M. with DM #3 confirmed the items observed in the dry storage area should have been dated upon opening and stored in an airtight container. DM #3 further confirmed expired foods should be discarded.
Review of facility policy titled Food Safety and Sanitation undated revealed perishable foods with expiration dates should be used prior to the use by date on the package. When a food package was opened, the food item should be marked to indicate the opendate and this date should be used to determine when to discard the food.
This violation represents noncompliance investigated under Complaint Number OH00167424.
R-0564Kitchen and dining areas clean and sanitary; transporting meals; garbage▼
Based on observation and staff interview, the facility failed to maintain kitchen trash in garbage cans with tight-fitting lids. This had the potential to affect all of the residents residing in the facility. The facility census was 108 residents.
Findings include:
Observation on 08/28/25 at 11:36 A.M. of the facility kitchen revealed there were four large trash cans filled with kitchen waste with no lids.
Interview on 08/28/25 at 11:40 A.M. with Dietary Manager (DM) #3 confirmed the four kitchen trash cans did not have lids covering them, and the facility did not have lids for those trash cans.
This violation represents noncompliance investigated under Complaint Number OH00167424.