Based on observation, medical record reviews, review of facility Self-Reported Incidents (SRI), facility policy review and interview, the facility failed to ensure all allegations of physical and/or emotional abuse were reported immediately to the Administrator and State Survey Agency as required. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm/injuries and psychosocial harm beginning on 09/05/24 at approximately 3:15 P.M. when Activity Director (AD) #400 witnessed State tested Nursing Assistant (STNA) #300 grab and force Resident #78 to sit in her specialty tilt-in-space wheelchair (a specialty wheelchair that offers both a tilting function and a reclining function and should not be considered an independent mobility device due to their size and… …
F609 citations in Ohio
Reporting alleged violations · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Ohio cites F609 less often than its own record predicts
1.00 times the national share — cited less often here than elsewhere.
Of every deficiency written in Ohio in 2025, this is the portion that was F609.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Ohio surveyors wrote
F609 findings written in Ohio, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on review of resident medical records, staff interviews, and facility policy review, the facility failed to report an incident of potential resident-to-resident abuse to the State Agency for two residents. This affected two residents (#15 and #48) out of three residents reviewed for abuse. The facility census was 68. Findings include: 1. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] and had diagnoses that included senile degeneration of the brain, dementia, anxiety disorder, and unspecified mood disorder. Review of Resident #15's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had a Brief Interview for Mental Status (BIMS) score of 03, indicative of severe cognitive impairment. …
Based on review of the facility's investigation, staff interviews and review of the Abuse, Neglect, Misappropriation Tool, the facility failed to report an allegation of missing medication to the State Agency. This had the potential to affect 49 of 49 residents who reside in the facility. Findings include: Review of the facility's investigation documentation revealed there was no documentation the State Agency was notified of an allegation of missing narcotic medication. Interview on 11/02/21 at 11:37 A.M. with the Director of Nursing (DON), revealed Licensed Practical Nurse (LPN) #110 was accused of misappropriating narcotics from the medication cart on 10/05/21, sometime after 3:00 A.M. Interview on 11/02/21 at 12:23 P.M. …
The short window
Recent years
| Year | Share of Ohio citations | vs expected |
|---|---|---|
| 2023 | 1.82% | 0.92× |
| 2024 | 2.22% | 0.97× |
| 2025 | 2.44% | 1.00× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Ohio surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction