Based on closed record review, facility investigation review, interviews and facility policy review, the facility failed to comprehensively assess and seek necessary medical intervention following an acute change in condition for Resident #93. This resulted in Immediate Jeopardy and serious injury, harm, significant impairment or death beginning on [DATE] at 7:00 P.M. when Resident #93, who was cognitively intact, was observed with slurred speech, a dazed/altered presentation, reported emesis, and an inability to independently operate his motorized wheelchair. Despite the identified acute change in condition, nursing staff failed to comprehensively assess the resident and notify the medical provider for direction and/or treatment. …
F684 citations in Ohio
Quality of care · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Ohio cites F684 more often than its own record predicts
1.08 times the share F684 takes of citations nationally.
Of every deficiency written in Ohio in 2025, this is the portion that was F684.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Ohio surveyors wrote
F684 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 record review, staff interview, and policy review, the facility failed to initiate prompt and appropriate care after a resident fell from a mechanical lift. This resulted in actual harm on 08/06/26 at approximately 3:00 P.M. when a mechanical lift being used to transfer Resident #78 had multiple batteries fail, requiring staff to use the mechanical lift's emergency release to lower the resident onto the floor. The facility also failed to recognize that Resident #78 suffered a fall and therefore the resident was not timely assessed, not provided a timely diagnosis and treatment resulting in the resident experiencing unnecessary pain. …
Based on review of resident medical records, staff interviews, and review of a facility policy, the facility failed to monitor a bruise after a fall for Resident #27. This affected one resident (#27) out of one resident reviewed for general skin conditions. Additionally, the facility failed to complete daily weight monitoring as ordered for Resident #81. This affected one resident (#81) out of one resident sampled for daily weight monitoring. The facility census was 68. Findings include: 1. …
The short window
Recent years
| Year | Share of Ohio citations | vs expected |
|---|---|---|
| 2023 | 4.17% | 1.15× |
| 2024 | 4.92% | 1.23× |
| 2025 | 4.64% | 1.08× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Ohio surveyors cite →
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