Citations in Ohio
Statistics, citations and compliance trends for long-term care facilities in Ohio.
Statistics for Ohio (Last 12 Months)
Financial Impact (Last 12 Months)
Latest citations in Ohio
Facility leadership failed to oversee resident care and staff performance effectively. Staff reported a week-long shortage of insulin syringes, during which nurses borrowed insulin pens and vials from other residents and gave them to different residents, while one resident missed insulin and another had delayed blood sugar checks and insulin coverage. Interviews also described an LPN threatening a resident, delayed incontinence care, intimidation of staff who reported concerns, and other allegations of misconduct, while the DON and RN/ADON did not fully investigate several of the reported issues.
Staff failed to timely report multiple allegations of abuse, neglect, misappropriation, and resident rights violations, including claims that a former CNA had sexual contact with residents for money, staff sold drugs to residents, and property was taken from a deceased resident. A resident also reported that an LPN did not complete ordered blood sugar checks and insulin coverage on time, and another resident was told to leave a unit or police would be called while he was calm and speaking with an RN. These events were known to staff and residents but were not reported to management or investigated before survey review.
Missed physician-ordered daily weights were found for three residents with conditions including CHF, CKD/ESRD, dementia, and diabetes. Records showed repeated gaps in weight documentation across multiple days, despite orders for daily monitoring, and the DON verified the missed weights and stated they should have been identified.
Improper Release of PHI: A staff member released a resident’s requested medical records to the resident’s son, but the packet also included skilled progress notes and other PHI for 12 unrelated residents. The error occurred when the staff member printed records from the EMR using only the first few letters of the resident’s name and did not recognize that multiple residents’ documents had been selected before sending the scanned records by secure email.
Urine Culture and Sensitivity Not Obtained as Ordered: A resident with a suprapubic catheter, quadriplegia, and a history of UTI had cloudy, odorous urine and diaphoresis. Urology ordered the catheter changed and urine collected for C&S, but although the specimen was placed in the specimen refrigerator, no C&S results were received and the DON later verified the lab had no record of the specimen being picked up.
A resident with CKD, HTN, and dialysis dependence was told by an LPN to leave another unit or police would be called, even though he was calm and was only speaking with an RN he knew well. The resident said he was trying to ask about delayed pain medication and later returned to the unit at shift change to talk with the RN. The RN confirmed he was calm and had not done anything, while the LPN acknowledged telling him to go back to his side and threatening police if he did not leave; the event was not documented or investigated by management.
Leadership and Oversight Failures Affecting Resident Care
Penalty
Summary
The facility failed to demonstrate effective leadership of overall operations to ensure residents received care as ordered and that staff actions were appropriately overseen. Review of job descriptions showed the Administrator was responsible for directing overall operations, the DON for overall management of resident care, and the RN/ADON for assisting with nursing management and training and for ensuring staff understood expectations for resident care. During the investigation, multiple staff interviews and resident statements showed breakdowns in oversight, communication, and response to care concerns across the facility. One major concern involved insulin administration and supply management. An Ombudsman asked the facility whether insulin needles were available for residents who had insulin orders. Staff reported that the facility was out of insulin syringes for about a week. During that time, LPNs stated they borrowed insulin pens or vials from other residents and administered those medications to different residents because they had no syringes available. One LPN stated she notified the RN/ADON that the facility was out of syringes and that nurses were taking and using other residents’ insulin. Another LPN stated she took another resident’s unopened insulin pen and gave it to a different resident. A third LPN stated she took one resident’s insulin vial and gave it to another resident. The RN/ADON stated she was responsible for ordering supplies but said she was not aware nurses were taking and administering other residents’ insulin. The DON stated she learned of the syringe shortage from the Ombudsman and did not interview residents or nurses about whether insulin had been missed or investigate beyond checking whether syringes were currently available. A resident also stated he missed insulin one day because there were no syringes, and on other days nurses took insulin from another resident so he would not miss his dose. The investigation also identified delayed insulin administration for another resident. That resident stated her blood sugar was supposed to be checked at breakfast, lunch, and dinner, but a former LPN did not check her breakfast or lunch blood sugar or give insulin as ordered. The former LPN acknowledged he was several hours late with the lunch blood sugar check and insulin coverage and said he did not contact the DON or physician when he fell behind. In addition, a resident reported an interaction with staff in which an LPN told him to leave the unit and threatened to call the police, while another nurse observed the resident was calm and not behaving aggressively. The RN/ADON stated she did not investigate that incident further after being notified. Additional interviews described prolonged incontinence care delays, intimidation of staff who reported concerns, allegations of inappropriate sexual conduct, theft of a resident’s bank card and jacket, and drug-related allegations involving staff and residents. The RN/ADON also acknowledged that wound care oversight, wound assessments, treatment completion, infection control, supply ordering, and day-to-day operational oversight were difficult to keep up with and that a surgical wound had not been fully assessed or treated as ordered.
Failure to Timely Report Abuse, Neglect, and Misappropriation Allegations
Penalty
Summary
Facility staff failed to timely report allegations of abuse, neglect, misappropriation, and resident rights violations involving multiple residents. The report states that allegations included staff taking a former resident’s bank card and leather jacket, a former CNA having sex with two former residents for money, staff showing breasts for money to residents, staff selling drugs to residents, and prolonged incontinence care concerns on the [NAME] Unit. The facility’s own interviews showed that these allegations were known to residents and staff, but they were not reported to management, the DON, the Administrator, the corporate compliance hotline, or investigated before surveyor review. Former Resident #75 had diagnoses including COPD, schizophrenia, and chronic respiratory failure, and his closed record contained no documentation of the alleged misappropriation of his bank card or leather jacket. Former Resident #79 and Former Resident #80 were both deceased under hospice services, and their records contained no documentation of the alleged sexual abuse or misappropriation. Resident #72 had diabetes, difficulty walking, and hyperlipidemia, and Resident #43 had CKD requiring dialysis and cellulitis; both were identified in allegations involving drug sales, but their records contained no documentation of those allegations. Resident #18 had hypertension and diabetes, and the record contained no documentation of the alleged proposition for money or sexual misconduct. The report also describes an incident involving Resident #32, who had diabetes and received insulin coverage before meals and at bedtime. On one day, the resident’s blood sugar checks and sliding-scale insulin were not completed at the ordered times; the morning and lunch checks were documented hours late, and no dinner blood sugar was documented. Resident #32 reported that the LPN did not check or treat her blood sugar as ordered and that she refused a later insulin dose because it was too close to the prior dose. Staff who heard the complaint did not report it, and the DON stated she was not aware of the incident because it had not been reported. Another event involved Resident #43, who was calm and talking with an RN on the [NAME] Unit when an LPN told him to leave or the police would be called. The resident and the RN both stated he had not been behaving aggressively at that time, and the RN felt the resident had the right to be on the unit. The LPN later acknowledged telling him to leave and threatening to call police, and the incident was not documented in the nursing notes or reported to management. The facility policy stated residents were free from abuse, neglect, misappropriation, and exploitation and that alleged violations were to be reported and investigated within required timeframes.
Missed Physician-Ordered Daily Weights
Penalty
Summary
The facility failed to ensure physician-ordered daily weights were obtained for three residents being monitored for medical conditions. Resident #30 had diagnoses including Alzheimer's disease, dementia, diabetes, edema, and CHF, and a physician order dated 03/02/26 required daily weights every night shift. The record showed multiple missed weights in March 2026, with no evidence weights were obtained on several dates throughout the month. Resident #36 had diagnoses including ESRD, SOB, CKD, diabetes, and CHF, and a physician order dated 03/27/26 required daily weights every day shift for health monitoring with notification for a four-pound or greater gain. The record showed missed weights in April 2026 on several dates. Resident #85, whose closed record showed diagnoses including CHF, dementia, Alzheimer's disease, COPD, and acute kidney failure, had a physician order dated 06/24/25 for daily weights related to monitoring fluid status. The record showed multiple missed weights in March and April 2026. A facility in-service record dated 03/10/26 showed staff education on obtaining daily weights. During interviews, the DON verified the missing weights for the three residents, stated the missed weights should have been identified, and said she did not have an explanation for why the weights were not completed as ordered.
Improper Release of Protected Health Information
Penalty
Summary
The facility failed to ensure the confidentiality of residents’ protected health information when it released medical records for one resident to that resident’s son and included records belonging to 12 other residents. An email from the resident’s son notified the facility that the scanned packet contained a total of 786 pages and included information from other residents. Facility leadership later verified that the breach occurred when staff scanned requested medical information and sent it by secured email, resulting in protected health information for 12 unrelated residents being disclosed. During interview, the Managed Care Coordinator stated she printed a report from the EMR by entering the first few letters of the resident’s name, saw the resident’s name on the top page, and then scanned the information to the son without recognizing that multiple residents’ records had been selected. The report identified that skilled progress notes containing protected health information for 12 residents were included in the release. The facility policy required PHI to be handled, stored, and communicated in accordance with regulations and required that release of PHI be limited to authorized staff and logged.
Urine Culture and Sensitivity Not Obtained as Ordered
Penalty
Summary
The facility failed to ensure a urine culture and sensitivity test was obtained timely and as ordered for a resident with an indwelling suprapubic catheter. The resident had multiple diagnoses including quadriplegia, extended spectrum beta lactamase, neurogenic bowel, chronic respiratory failure, urinary tract infection, neuromuscular dysfunction of the bladder, chronic pain syndrome, diabetes, seizures, and hydronephrosis with ureteral stricture. A quarterly MDS assessment documented intact cognition and an indwelling catheter. On 05/19/26, the resident was noted to be diaphoretic with elevated blood pressure, and the catheter was draining cloudy, odorous urine. The catheter was flushed and continued draining, urology was contacted, and the nurse practitioner ordered a CBC and BMP. On 05/20/26, urology returned the call and ordered the suprapubic catheter changed in house, urine collected for culture, results faxed to urology, and minocycline started. The catheter was changed and the specimen was collected and placed in the specimen refrigerator, but the record contained no urine culture and sensitivity results from 05/20/26 through 05/29/26. The Corporate DON later verified the laboratory never received the specimen and had no record of the urine culture and sensitivity being picked up.
Resident Told to Leave Unit and Police Threatened During Calm Interaction
Penalty
Summary
The facility failed to maintain Resident #43’s rights to dignity, self-determination, and communication when staff told him to leave a unit and threatened to call the police if he did not comply, even though he was calm and was only speaking with an RN he knew from prior work on that unit. Resident #43 was admitted with chronic kidney disease, hypertension, and dependence on renal dialysis. His MDS reflected intact cognition and no behaviors, although the care plan later identified behaviors such as demanding medications, verbal aggression, swearing, and making false allegations. On 05/03/26, Resident #43 reported that he was in significant pain from a bad tooth and was waiting for pain medication that was due around 2:45 A.M. but was not received until about 4:10 A.M. He stated that after he found the LPN on the other unit and questioned her about the delay, the police were called and he eventually received his medication. Later that morning, he went to the other unit at shift change to speak with the RN, with whom he had a good rapport, and he stated he was calm and had not said anything to the LPN when she told him to get off the unit or she would call the police. The RN confirmed Resident #43 was calm and had not displayed any behavior when he came onto the unit to talk with her, and she felt the LPN had threatened him by telling him to leave or the police would be called. The LPN acknowledged telling him to go back to his side and that she would call the police if he did not leave, and later told management she had done wrong. The incident was not documented in the nursing notes, and management stated they had not been informed or investigated the matter further. The resident’s care plan and behavior contract did not include restricting him from the unit or calling police if he remained there while calm.
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Compliance trends in Ohio
Data through Apr 2026Comparisons below measure the most recent period May 2025 – Apr 2026 against the prior period May 2024 – Apr 2025 (two equal 12-month windows). The most recent 1 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 1-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 1 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025; the most recent 1 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 1 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
Trusted data from CMS and state health departments
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