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
A resident who was dependent on two staff and required a mechanical sling lift for all transfers was manually moved from bed to wheelchair by two CNAs without the lift while an LPN briefly left the room. During the transfer, the resident's leg became trapped under the wheelchair, but the event was not promptly reported to nursing or medical providers. The resident later developed ongoing pain and swelling, was found to have multiple fractures after an X-ray and ER evaluation, declined, was transferred to hospice, and died from complications of the injuries.
A resident with multiple chronic conditions and frequent incontinence had a urine culture ordered for altered mental status. The facility received an abnormal culture showing ESBL Klebsiella but did not report it to the NP for several days, and treatment was delayed until the resident was later found slow to respond with bradycardia and unresponsiveness and was sent to the hospital, where UTI, AKI on CKD, and IV antibiotics were documented.
Uncomfortable Resident Room Temperatures: The facility failed to keep resident room temperatures at a comfortable level for 25 residents. During survey observations, two AC units were out, room temperatures ranged from 68 to 80.4 degrees, and several residents said their rooms were too hot or too warm. Staff confirmed the AC problem had been ongoing for weeks, while temperature logs showed hallway readings but no room temperatures were recorded by Maintenance.
Unsafe and Uncomfortable Room Temperatures: Surveyors observed multiple common areas and resident rooms above the facility’s allowed temperature range, with some areas reaching 90 degrees or higher. Residents were seen using washcloths for relief, and a resident reported the room felt hot. The Maintenance Director verified the readings, and the issue affected nearly all residents in the facility.
Infection Control and Medication Handling Failures: An LPN entered a room on contact precautions without a gown or gloves, handled wound care supplies and dressing changes without proper hand hygiene between glove changes, and a roommate without isolation needs was cohorted with a resident on CRAB precautions despite available rooms. In separate observations, an RN and an LPN handled medications with bare hands, including a tablet dropped on the med cart, instead of following infection control procedures.
Failure to perform hand hygiene was observed during resident care and when moving between residents. Two CNAs assisted a resident with toileting, removed gloves, and left the room without hand hygiene, then entered two other residents’ rooms without cleaning their hands. One CNA sat on a resident’s bed and talked with the resident, and another assisted with a bedside table, both without hand hygiene on entry or exit. Interviews confirmed the missed hand hygiene, and facility policy required hand hygiene before and after glove removal, after contact with potentially contaminated surfaces, and before caring for another resident.
Unsafe Transfer of a Non-Ambulatory Resident
Penalty
Summary
The facility failed to ensure a resident who was dependent on two staff members and required a mechanical sling lift for all transfers was transferred safely and according to the plan of care. The resident had diagnoses including dementia, Parkinson's disease, reduced mobility, osteoarthritis, chronic obstructive pulmonary disease, and an unstageable sacral pressure ulcer. Her care plan and physician orders both directed that all transfers be completed with a mechanical sling lift and two assists because she was unable to bear weight. On the evening of the incident, the resident was being moved from bed to wheelchair when an LPN exited the room and two CNAs manually transferred her without using the mechanical sling lift. During the transfer, the resident's right leg became positioned under the wheelchair, and staff later reported that the leg was gently repositioned. The event was not reported to additional staff or medical providers at the time. The resident later had continued complaints of pain, swelling, and warmth in the lower extremities, and change-in-condition evaluations documented new or worsening pain and edema. An X-ray was eventually obtained and showed a right femur fracture. The resident was sent to the emergency room, where additional fractures were identified, including a fracture to the right shin and a left tibial plateau fracture. Hospital records noted that she was not a surgical candidate. Following the fractures, the resident declined, was transferred to inpatient hospice, and later died due to complications from multiple fractures. Interviews with staff and family described that the resident had ongoing leg pain and swelling before the fracture was identified, and staff acknowledged that the resident should have been transferred with the mechanical lift.
Delayed Reporting of Abnormal Urine Culture and UTI Treatment
Penalty
Summary
The facility failed to ensure Resident #44 received treatment and care in accordance with professional standards of practice for a urinary tract infection. Resident #44 was admitted with multiple chronic conditions, including stage three pressure ulcer, malnutrition, heart disease, dysphagia, weakness, and frequent bowel and bladder incontinence. Her care plan included monitoring for signs and symptoms of UTI, and a quarterly MDS showed she was cognitively intact but medically complex and dependent for toileting hygiene. On 06/03/26, a urine specimen was collected after a provider ordered a urinalysis with culture and sensitivity for altered mental status. The lab report, dated 06/07/26, showed the urine culture was positive for Klebsiella pneumoniae ESBL greater than 100,000 colony-forming units per milliliter. Although the facility received the result on 06/07/26 at 2:38 P.M., there was no evidence the abnormal result was reported to the NP or physician until 06/16/26 at approximately 9:51 P.M. Progress notes from 06/07/26 through 06/15/26 did not show that the culture result was communicated to the provider. After the delayed report, new orders were entered for nitrofurantoin. Later that evening, Resident #44 was found during medication pass to be slow to respond, not opening her eyes, and not responding to sternal rub, with a pulse of 44 and blood pressure of 108/63. She was transferred to the hospital shortly after midnight and admitted for bradycardia and unresponsiveness. Hospital records showed acute kidney injury on chronic stage three kidney disease and UTI, with urine testing positive for E. coli and Klebsiella pneumoniae. She required a nine-day hospitalization, infectious disease consultation, PICC placement, and IV antibiotics.
Uncomfortable Resident Room Temperatures
Penalty
Summary
The facility failed to ensure temperatures in resident rooms and common areas were maintained at a comfortable level for 25 residents out of a census of 142. During an observation with the Maintenance Director, two air conditioning units were reported to be out and had been out for a couple of weeks, with repair planned in the next few days. Room temperatures observed during the survey ranged from 68 degrees to 80.4 degrees, and rooms at 80 degrees did not have window AC units. Daily temperature logs from 06/01/26 to 06/11/26 showed hallway temperatures from 71 degrees to 78 degrees, but no room temperatures were taken by Maintenance. Maintenance logs from April 2026 through June 2026 showed no concerns with the air conditioning. Residents interviewed during room temperature checks stated their rooms were too hot or too warm, including residents whose rooms measured between 72.7 degrees and 80.4 degrees. Several residents reported using fans, opening windows, or going into the hallway to cool off, and one resident stated the air was broken. Staff interviews confirmed the air conditioning had been an ongoing issue, had gone out the prior year as well, and had been broken for a few weeks. The facility policy titled Homelike Environment stated residents are to be provided a safe, clean, comfortable and homelike environment with comfortable and safe temperatures between 71 degrees Fahrenheit and 81 degrees Fahrenheit.
Unsafe and Uncomfortable Room Temperatures
Penalty
Summary
The facility failed to ensure resident rooms and common areas were maintained at comfortable and safe temperatures. During observation, residents in the front lobby were seen wearing weather-appropriate clothing with white washcloths around their necks or on top of their heads. At 4:17 P.M., surveyors observed multiple common areas above 82.0 degrees Fahrenheit, including the 100 hall way at 82.7 degrees Fahrenheit, the locked memory care unit dining room at 88 degrees Fahrenheit, and the 400 hall at 90 degrees Fahrenheit. Surveyors also measured numerous resident rooms above the facility’s policy range of 71 to 81 degrees Fahrenheit, including rooms recorded at 82.1, 84.8, 90.0, 83.0, 85.0, 86.0, 83.3, 86.2, 87.2, 87.5, 87.9, 86.1, 89.1, 90.9, 90.1, 91.1, 91.9, 91.0, 90.0, and 90.2 degrees Fahrenheit. The Maintenance Director verified the temperature readings as they occurred, and a resident stated the room felt hot. The facility census was 74, and the deficiency affected all residents except 15 named residents whose rooms and common areas were maintained at an appropriate temperature.
Infection Control and Medication Handling Failures
Penalty
Summary
The facility failed to implement appropriate infection control practices for a resident on contact precautions for carbapenem-resistant Acinetobacter baumannii (CRAB). Resident #47 had diagnoses including osteomyelitis of the vertebra, paraplegia, CRAB carrier status, and an open wound to the right lower leg, and was ordered to be on contact precautions for wounds, an indwelling Foley catheter, and history of CRAB. Resident #46, who had severely impaired cognition and no isolation precautions ordered, was housed in the same room as Resident #47 even though the Administrator verified other rooms were available. A sign on the room door indicated contact precautions with gown and gloves required before entry. During observation, an LPN entered the room without donning a gown or gloves and cleared items from Resident #47’s bedside table before leaving to gather wound care supplies. During wound care, the LPN donned gown and gloves, removed the old dressing, and then used the same gloved hand to retrieve clean gauze and wound wash from the bedside table. The LPN removed gloves and put on new gloves without performing hand hygiene between glove changes, then continued the dressing change. The LPN later removed gloves again, wrote the date on the dressing, and applied new gloves without hand hygiene before continuing care. The LPN acknowledged she did not don clean gloves after removing the dirty dressing and did not perform hand hygiene between glove changes. The report also identified medication administration practices that did not follow infection control procedures. For Resident #38, an RN prepared 11 scheduled medications by pushing them through blister foil and placing each medication in her bare hand before putting them into a medication cup and administering them. For Resident #21, an LPN dropped a dapagliflozin tablet onto the medication cart, picked it up with her bare hand, placed it in the medication cup, and administered it. The LPN acknowledged the tablet should have been discarded. The facility policy for administering medications stated staff were to follow infection control procedures, including handwashing, antiseptic technique, gloves, and isolation procedures as applicable.
Failure to Perform Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to ensure staff completed hand hygiene during care and when moving between residents. Resident #02 was admitted with diagnoses including epilepsy, neuromuscular dysfunction of the bladder, atrial fibrillation, and obesity, and the quarterly MDS showed intact cognition with a BIMS score of 15. The resident was dependent for lower-body dressing and toileting hygiene and required substantial to maximal assistance for bathing and personal hygiene. During observation, two CNAs assisted Resident #02 to the bathroom toilet using a sit-to-stand lift, removed their gloves, and exited the room without performing hand hygiene before donning gloves or after removing them. After leaving Resident #02’s room, one CNA entered Resident #07’s room, turned off the call light, sat on the resident’s bed, talked with the resident, and exited without performing hand hygiene on entry or exit. Resident #07 had diagnoses including right heart failure, Type Two Diabetes, and chronic kidney disease stage three, and the quarterly MDS showed a BIMS score of 14. Another CNA then entered Resident #17’s room, talked with the resident, and assisted with the bedside table without performing hand hygiene when entering or exiting. Resident #17 had diagnoses including multiple sclerosis, major depression, and mild cognitive impairment, and the quarterly MDS showed a BIMS score of 15. Interviews with both CNAs confirmed they did not perform hand hygiene as observed. Facility policy stated hand hygiene is performed before and after removing gloves, after touching potentially contaminated surfaces or items, and before caring for another resident.
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Compliance trends in Ohio
Data through May 2026Comparisons below measure the most recent period Jun 2025 – May 2026 against the prior period Jun 2024 – May 2025 (two equal 12-month windows). The most recent 2 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 2-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): Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Jun 2025 – May 2026 vs the prior period Jun 2024 – May 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: Jun 2025 – May 2026 vs the prior period Jun 2024 – May 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 Jun 2025 – May 2026 vs the prior period Jun 2024 – May 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 2 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025; the most recent 2 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 2 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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