Based on observation, record review, review of facility billing/financial information, review of the facility assessment, review of the Administrator and Director of Nursing Job Description, and interviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident resulting in Immediate Jeopardy and actual harm or the potential for serious harm, injury and/or death to all facility residents. The facility administration failed to take appropriate action resulting in substandard quality of care deficiencies identified under Freedom from Abuse, Neglect, and Exploitation and Quality of Care. …
F835 citations in Ohio
Administration · Administration Deficiencies
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Ohio cites F835 more often than its own record predicts
1.42 times the share F835 takes of citations nationally.
Of every deficiency written in Ohio in 2025, this is the portion that was F835.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Ohio surveyors wrote
F835 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 medical record review, staff interview, observation, review of emergency medical service (EMS) records, review of hospital records, review of facility guidance, review of the facility's policy for cardiopulmonary resuscitation (CPR), and review of American Heart Association (AHA) guidance, the facility failed to be administered in a manner that utilized its resources effectively and efficiently to ensure resident safety. This deficient practice affected one (#49) of one residents found unresponsive in the facility with CPR initiated. This had the potential to affect 18 (#10, #11, #12, #13, #14, #15, #16, #17, #19, #20, #22, #25, #27, #40, #41, #43, #47, and #48) designated with a full code resuscitation status. …
Based on interview, record review, and Employee Handbook review, the facility failed to ensure staff were awake at all times to effectively meet the needs of all residents. This had the potential to affect all 81 residents in the facility. Findings include:1. Review of employee personnel file for Dietary Aide (DA) #293 revealed a Disciplinary Action Form dated 12/19/25 for termination for sleeping on the job in the main lobby. Attached to the form was a statement dated 12/19/25 signed by Human Resource (HR) #230 and Administrator. HR #230 found DT #293 sleeping in the lobby and got the Administrator to witness. HR #230 woke DT #293 up and he apologized stating he did not fully intend to fall asleep but had not slept well the night before. Interview on 12/22/25 at 7:57 A.M. …
The short window
Recent years
| Year | Share of Ohio citations | vs expected |
|---|---|---|
| 2023 | 0.20% | 0.68× |
| 2024 | 0.42% | 1.28× |
| 2025 | 0.42% | 1.42× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Ohio surveyors cite →
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