Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Arc At Cincinnati during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, dependence for mobility, and a history of left femur fracture reported an unwitnessed fall and developed left leg and knee pain with swelling. An NP assessed the resident, documented pain and limited ROM in the left leg, but initially entered STAT imaging orders for the wrong limb, leading to X-rays of the right hip and knee that only showed arthritis. Nursing documentation of the fall was absent, and assessment notes contained contradictions about the left leg findings. Orders for X-rays of the left hip and knee were written the following day, along with oral pain medications and a Lidocaine patch, but the left-sided imaging was not completed until several days later, when a suspected distal femur fracture was finally identified. The resident was then transferred to the hospital, where a bicondylar distal femur fracture was confirmed and treated surgically with ORIF. Surveyors determined the facility failed to provide timely treatment of the fracture, resulting in actual harm to the resident.
A resident with a history of repeated falls and multiple comorbidities had a care plan that included non-skid strips on the floor beside the bed as a fall prevention intervention. During surveyor observation, the resident’s bedside area lacked these non-skid strips. A CNA, maintenance staff, and the DON each confirmed that non-skid strips were not in place, and maintenance reported that none were available in the facility. This failure to implement the care-planned intervention occurred despite a facility policy requiring comprehensive person-centered care plans to be developed and implemented.
A resident with multiple care needs and a care plan requiring two-person assistance for all personal care was provided a bed bath by a single CNA. During care, the resident experienced a leg spasm, fell from the bed, and sustained fractures in both legs. Staff interviews confirmed that care was routinely provided by only one CNA, contrary to the documented care plan and facility policy.
A resident with multiple complex medical conditions who was dependent on staff for mobility did not attend scheduled outside medical appointments due to failures in scheduling and arranging transportation. Confusion and poor communication between nursing staff and the transportation coordinator led to missed appointments, with no documentation that transportation was arranged or that appointments were attended, despite physician orders and facility policy requiring such arrangements.
A resident who required two staff for bathing was left unattended by only one staff member, resulting in a fall and fractures to both legs. Other deficiencies included a resident keeping a prohibited electric coffee pot in their room, medications left at the bedside without proper orders or labeling, and a room with a loose metal chair rail and splintered wood, all of which were unaddressed by staff and posed safety hazards.
A resident with chronic pain and opioid dependence missed multiple doses of prescribed methadone due to pharmacy dispensing issues, prescription diagnosis errors, and delays in obtaining new prescriptions or prior authorizations. This led to increased pain, withdrawal symptoms, and emergency room visits. Staff interviews revealed inconsistent medication reordering practices and inadequate documentation, resulting in actual harm to the resident.
Staff conducted verbal shift reports at the nurses' station where residents could overhear protected health information, including diagnoses and medications. Multiple residents with intact cognition reported overhearing confidential details, and an LPN confirmed that this practice occurred and constituted a HIPAA violation. The DON stated that private areas were available for such reports, and facility policy required confidentiality, but these procedures were not followed.
Several nurses did not receive required training on abuse, neglect, and exploitation during orientation or annually, as mandated by facility policy. Employee file reviews and staff interviews confirmed missing documentation of this training, despite expectations set by facility leadership and policy requirements. This deficiency had the potential to affect all residents in the facility.
Surveyors identified expired medications stored in medication rooms and carts, as well as missing and incomplete temperature monitoring for medication refrigerators. An LPN and the DON indicated unclear staff responsibilities and inconsistent training regarding these duties, resulting in expired drugs being accessible and temperature logs not being maintained as required by facility policy.
Staff failed to follow infection control protocols by discarding used towels on the shower room floor and allowing shared use of unlabeled personal care items among residents. Additionally, two residents with respiratory conditions had their nebulizer and CPAP equipment left uncovered and improperly stored, despite staff awareness of correct procedures. Both the DON and Administrator confirmed expectations for individual labeling and proper storage, but these practices were not consistently followed.
Damaged resident equipment was left in use when a resident’s fall mat was repeatedly observed torn with exposed foam and black stains, and staff said it had been in that condition for weeks without being reported. A shower bench on the Willow Unit was also observed with cracked vinyl, exposed foam, and a worn, torn surface, and staff stated the condition had not been reported even though it had been noticed for a long time.
IV hydration with micronutrients was provided to multiple residents with conditions such as paraplegia, wounds, DM, and cognitive impairment, but the facility did not establish or document clear medical necessity criteria, and some screening tools were incomplete or unsigned. Records showed repeated NS infusions with added vitamins/minerals, limited lab monitoring, and inconsistent documentation of intake/output. The contract and provider records for the outside IV therapy company also did not align with Ohio licensing and filing requirements, while facility leaders and the NP said they had minimal involvement and did not know the program’s criteria or protocols.
IV Therapy Program Lacked Required Oversight and Compliant Procedures: The facility used an outside IV therapy company to provide hydration and micronutrient infusions to multiple residents with complex medical conditions, including paraplegia, pressure ulcers, DM, hemiplegia, and cognitive impairment. Records showed inconsistent screening documentation, missing nursing signatures, absent or incomplete monitoring orders, infusion complications such as infiltration, and staff who said they had minimal involvement and were unfamiliar with the company’s policies, procedures, and licensure status.
The facility did not maintain ongoing communication with dialysis providers for two residents requiring hemodialysis. Staff interviews and record reviews showed that information was not consistently sent to or received from the dialysis center, and required communication sheets were not regularly used. This resulted in a lack of documentation and exchange of critical care information between the facility and the dialysis provider.
Three residents experienced significant medication errors when staff failed to administer medications as ordered, including not updating an eye drop order after an optometrist visit, giving an antipsychotic at the wrong time of day, and missing doses of an antiplatelet medication without documentation or physician notification. Nursing staff and the DON confirmed that these errors resulted from missed order updates and transcription mistakes.
A resident with chronic pain and opioid dependence was prescribed methadone, but nursing staff signed the MAR as if the medication was administered on several occasions when it was not, as confirmed by the absence of narcotic sheet documentation and staff interviews. The resident also reported missed doses due to pharmacy supply issues, and facility leadership acknowledged that this resulted in inaccurate medical records.
Failure to Notify Responsible Party of Tube Feeding Change: A resident with persistent vegetative state, severe protein-calorie malnutrition, and gastrostomy status had a tube feeding order changed from scheduled feedings to continuous 24-hour feedings. There was no documentation that the resident’s responsible party was notified or approved the change, and the responsible party stated they were unaware of it and would not have approved continuous feedings because the resident could not tolerate them. The DON said an alternate RD recommended the change but did not communicate it to the responsible party, despite facility policy requiring prompt notification of the resident, attending MD, and resident representative when status or treatment changes.
Failure to Provide ADL Hygiene Assistance: A resident with legal blindness and MS, who required substantial to dependent help with personal hygiene, was observed with long, dirty fingernails and untrimmed facial hair after a bed bath. The resident stated staff had not offered to clean or trim his nails or shave him, and CNA and LPN staff confirmed the nails were dirty, jagged, and long and that he needed to be shaved. The DON and Administrator stated staff were expected to provide these hygiene services as needed.
A resident with a feeding tube, persistent vegetative state, and severe malnutrition did not receive enteral nutrition as ordered. Staff observed the tube feeding not hanging or infusing at times, and later found it running at the wrong rate; an RN said he forgot to hang it and had not read the current order, while an LPN followed an outdated schedule instead of the active order. The DON and Administrator stated tube feedings should be administered according to current orders.
Failure to maintain oxygen humidification for a resident receiving supplemental O2. A resident with chronic respiratory failure, COPD, CHF, and shortness of breath was ordered humidified O2 via nasal cannula, but repeated observations found the humidifier bottle dated 11/25 and empty while the resident was on 3 LPM. The resident reported nasal dryness, and staff stated humidifier bottles should be changed when empty; the facility policy required checking that water was present in the humidifying jar.
Failure to provide routine dental services for a resident with moderate cognitive impairment, aphasia, limited ROM, and broken carious natural teeth. The resident’s record showed no dental consult order and no documentation of any dental appointment since admission, despite a care plan directing staff and social services to coordinate dental care. The MRD stated the resident’s representative needed to consent, but there was no documentation that the representative was contacted, and the DON and Administrator stated dental services should occur at least yearly or twice yearly.
A resident with multiple chronic conditions was found unresponsive after an unwitnessed fall, and staff did not complete a required post-fall investigation as outlined in facility policy. Interviews with the DON, ED, ADON, and an RN confirmed the omission, resulting in a deficiency related to fall management.
A resident with cognitive impairment and multiple medical conditions underwent several room changes without proper documentation of the reasons or written notification to the resident and their representative. Staff interviews and record reviews confirmed the absence of required notifications and documentation.
Staff failed to consistently recheck and notify providers about abnormal blood pressure readings for a resident with multiple chronic conditions. On two occasions, the resident had significantly high and low blood pressure readings without follow-up or provider notification, contrary to facility policy and staff expectations as confirmed by interviews with nursing and medical staff.
A resident with multiple risk factors for skin breakdown did not receive required weekly skin assessments or consistent turning and repositioning, as documented by gaps in CNA records. When new pressure ulcers developed, there were delays and incomplete documentation of physician-ordered wound care. Staff interviews confirmed that assessments and interventions were not completed as ordered, resulting in the resident developing advanced stage pressure ulcers and experiencing actual harm.
A registered nurse left a resident's EMR containing confidential health information open and facing the hallway, making it visible to others while administering medications. The resident had multiple diagnoses and moderate cognitive impairment. This action was not in accordance with the facility's policy on medical record confidentiality.
An LPN administered Lorazepam and Modafinil, both controlled substances, to a resident with multiple medical conditions without verifying the medication count or signing out the medications in the controlled substance log, contrary to facility policy requiring proper documentation and accountability for controlled substances.
A nurse failed to administer two prescribed medications to a resident with multiple chronic conditions because the medications were unavailable, resulting in a medication error rate of 7.7% during observed medication passes. This exceeded the regulatory limit of 5% and was identified as a deficiency during the survey.
Surveyors observed that staff failed to follow infection control protocols during medication administration and wound care. An RN did not wear an isolation gown while assisting with wound care for a resident on EBP, and two nurses handled medications improperly—one by placing pills directly into bare hands, and another by picking up a dropped pill with a gloved hand and not performing hand hygiene between residents.
A resident with a history of bipolar disorder and schizophrenia was discharged from a facility without a 30-day notice and was initially sent to a homeless shelter, which refused him due to past behaviors. The facility did not attempt to find alternative placement and relied on a caseworker's plan, leading to the resident being taken to multiple hospitals before being admitted. The facility's policy on discharge was not followed.
The facility failed to prevent and treat pressure ulcers in residents, leading to the development of avoidable stage III pressure ulcers. Despite physician orders for interventions like heel protectors and a low air loss mattress, these were not implemented timely. The lack of a quick reference system for staff and failure to follow the facility's policy on skin assessment contributed to the issue.
The facility's phone system malfunctioned, preventing communication with staff and affecting all 84 residents. Observations over several days showed repeated failed attempts to reach personnel, with calls redirected to a generic message without options to transfer. The Administrator and Receptionist confirmed the issue, which was reported by a family member.
The facility failed to serve meals at palatable temperatures, affecting nearly all residents. During a meal service observation, food temperatures dropped significantly by the time they were served, with chili mac at 96°F, cornbread at 92°F, and milk at 50°F. Residents confirmed their meals were cold and bland, and the Dietary Manager acknowledged the issue, despite a policy to monitor food temperatures.
The facility failed to ensure a safe and homelike environment, affecting 23 residents. Observations revealed damaged drywall in a resident's room and multiple ceiling tiles with brown stains in the therapy gym and common areas, indicating potential water damage. These conditions were confirmed by the Maintenance Director.
A facility failed to implement its policy on injuries of unknown origin when a resident with severe cognitive impairment was found with scratches on her face. Initial documentation by an LPN was struck out by the Interim DON, who claimed the injury did not occur as described. Despite the facility's policy requiring immediate reporting and investigation, the incident was not properly addressed, leading to a deficiency.
A resident with severe cognitive impairment was found with scratches on her face, but the facility failed to report the injury of unknown origin to the state agency in a timely manner. Despite documentation by an LPN and witness statements from CNAs, the interim DON struck out the records, claiming the incident did not occur. The facility's policy required immediate reporting of such incidents, leading to a deficiency citation.
A resident with severe cognitive impairment was found with scratches on her face, but the facility failed to investigate the injury thoroughly. Despite initial documentation by an LPN and notifications to the physician and family, the interim DON struck out the records, claiming incorrect information. Interviews confirmed the injuries, but the facility did not adhere to its policy for investigating such incidents.
A resident admitted with multiple health conditions did not receive their prescribed medications on the evening of admission and the following morning. Despite the availability of some medications in the facility's Pyxis system, they were not administered, and the physician was not notified of the missed doses. The facility's policy on medication errors was not followed, as no incident report or nursing notes were completed.
A resident with severe cognitive impairment and multiple medical conditions was inappropriately restrained with a sheet by an STNA to prevent falls. The resident exhibited aggressive behavior and attempted to get out of the wheelchair, leading to the unauthorized use of the sheet as a restraint. The incident was documented and confirmed through staff interviews and observations.
The facility failed to update a resident's fall care plan with current interventions, despite the resident being at risk for falls and using a low bed and fall mats. This deficiency was confirmed through observations and staff interviews, revealing non-compliance with the facility's fall risk management policy.
Delayed and Incorrect Imaging Orders Resulting in Untimely Treatment of Femur Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely and accurate treatment of a resident’s left leg fracture following a reported unwitnessed fall. The resident had multiple diagnoses, including prior fractures of the left femur, ischemic cardiomyopathy, cerebral infarction, type II diabetes, and heart failure, and was care planned as being at risk for pain with interventions to evaluate the effectiveness of pain interventions. The resident had severely impaired cognition, verbal behaviors, and was dependent on staff for toileting, mechanical lift transfers, and bed mobility. On the date of the incident, the nurse practitioner (NP) acutely evaluated the resident after reports of a possible fall out of bed, with the resident stating he rolled out of bed onto the floor on his right side with knees colliding. There was no nursing documentation of a fall or change-in-plane status. The NP’s documentation regarding the left leg was contradictory, noting both no crepitus or difficulty with passive range of motion (ROM) and that the resident reported pain with passive ROM and did not participate in active ROM. The NP documented that STAT imaging was ordered and gave verbal orders for acetaminophen and a Lidocaine patch, with a plan to re-evaluate the resident in the morning. Later that afternoon, a registered nurse documented that the resident reported an unwitnessed fall on the previous shift and complained of left knee pain with apparent swelling. The RN notified the NP, who assessed that the resident was unable to participate in ROM to the left leg due to pain and placed new orders for an X-ray to the left leg, a one-time dose of acetaminophen, and a Lidocaine patch to the left leg. However, the actual physician orders entered on that date were for a STAT X-ray of the right hip and a Lidocaine patch to the right posterior hip, along with acetaminophen. X-rays completed that evening were of the right knee and right hip, both showing only modest arthritis and osteoarthritis, respectively. The next day, an untimed progress note documented left knee swelling related to the unwitnessed fall and referenced the right hip X-ray findings. New orders were then placed for X-rays of the left hip and left knee, as well as oral anti-inflammatory medication, a muscle relaxer, and a Lidocaine patch to the left posterior hip for pain. Despite the orders for left hip and knee imaging being written the day after the initial evaluation, the X-rays of the left knee and hip were not completed until two days later. When performed, the imaging showed the left knee was highly suspicious for a minimally displaced distal femoral metaphyseal fracture, while the left hip showed only mild degenerative changes without acute fracture or dislocation. The NP later documented reviewing the left-sided X-ray results and arranged for the resident to be sent to the hospital for further evaluation of a suspicious, non-confirmed fracture of the left leg. Hospital records showed the resident was admitted and treated for a closed bicondylar fracture of the left distal femur with open reduction and internal fixation. The resident reported having fallen out of bed on the left side while at the facility but could not provide more information due to baseline dementia, and the hospital was unable to obtain further details from facility staff. Interviews confirmed that the NP acknowledged placing the initial orders for the wrong limb and that the facility’s medical director was not informed of the alleged fall, the fracture requiring surgery, or the incorrect orders until a later date. The facility’s policy on attending physician responsibilities required appropriate and timely medical orders and treatments to enable safe, effective continuing care. Surveyors concluded that the facility failed to ensure timely treatment of the resident’s left leg fracture, resulting in actual harm. The sequence of events included an unwitnessed fall without nursing documentation, contradictory assessment notes, incorrect initial imaging orders for the right side instead of the left, and a delay of several days before the correct left-sided imaging was completed and the fracture identified. This failure affected one resident reviewed for care post fall out of a facility census of 89.
Failure to Implement Care-Planned Non-Skid Floor Strips for Fall Prevention
Penalty
Summary
The deficiency involves the facility’s failure to implement a care-planned fall prevention intervention for a resident identified as being at risk for falls. The resident had multiple diagnoses, including multiple rib fractures, unspecified bipolar disorder, recurrent major depressive disorder, unspecified anxiety disorder, chronic pain syndrome, repeated falls, and stage IV chronic kidney disease. An annual MDS assessment documented that the resident was cognitively intact, had no behaviors, did not reject care, and did not wander. The resident’s care plan, dated 08/14/24, identified fall risk related to refusing environmental modifications, self-medicating, alcohol use, use of mobility devices, and clutter in the room. Among the listed interventions were a cushion in the wheelchair, anti-roll backs to the wheelchair, encouraging use of the call light, a new bed/mattress, education on appropriate footwear, encouraging the resident to keep the bed in the lowest position, non-skid strips to the floor next to the bed, and family decluttering the room. Surveyor observation on 01/27/26 at 12:07 P.M. showed that the resident did not have non-skid strips on the floor beside the bed, despite this being a care-planned intervention. A CNA confirmed at the same time that there were no non-skid strips at the bedside. Later that day, a maintenance staff member verified that the resident did not have non-skid strips on the floor in the room and stated that non-skid strips would have to be ordered because none were available in the facility. On 01/28/26, the DON also confirmed that the resident did not have non-skid strips at the bedside as specified in the care plan. Review of the facility’s Comprehensive Person-Centered Care Plans policy, dated March 2022, indicated that each resident was to have a comprehensive care plan developed and implemented to meet physical, psychological, and functional needs. This deficiency was cited under a complaint investigation and was a recite to a prior annual survey.
Failure to Follow Two-Person Assistance Care Plan Results in Resident Fall and Fractures
Penalty
Summary
The facility failed to implement person-centered care planned interventions for a resident who was dependent on staff for all aspects of personal care, including bathing and bed mobility. The resident, who had diagnoses such as absolute glaucoma, muscle weakness, difficulty walking, and required total assistance, had a care plan specifying that two staff members were required for all care. Despite this, a single CNA provided a bed bath without assistance, during which the resident experienced a leg spasm, fell from the bed, and sustained fractures in both legs. The care plan and MDS documentation clearly indicated the need for two-person assistance, but this intervention was not followed. Interviews with staff confirmed that the resident was always cared for by one CNA, despite the care plan's directive. The CNA involved stated that she never received help from other staff members when providing care to this resident. The incident resulted in the resident being transported to the hospital and not returning to the facility. Facility policy required staff to follow care planned interventions and to implement measures to prevent falls, but these were not adhered to in this case.
Failure to Arrange and Document Transportation for Scheduled Medical Appointments
Penalty
Summary
The facility failed to ensure that a resident was taken to scheduled outside medical appointments, as required by physician orders and the resident's care plan. The resident in question was admitted with multiple complex diagnoses, including paraplegia, autonomic dysreflexia, neuromuscular bladder dysfunction, anxiety disorder, chronic pain syndrome, and major depressive disorder. The resident was dependent on staff for all mobility needs and required stretcher transportation due to being bedbound. Upon admission, the resident had existing appointments scheduled and orders for additional appointments, with instructions for staff to arrange transportation. Despite these requirements, a review of the medical record and interviews with staff revealed that the necessary appointments were not scheduled or attended. The process for arranging appointments and transportation involved multiple staff members, including nurses and the transportation coordinator, but there was confusion and lack of clear responsibility. Nurses were responsible for scheduling appointments and notifying the transportation coordinator, who would then arrange transportation. However, conflicting information, missed communications, and lack of documentation led to appointments not being made or attended. Staff interviews confirmed that there were ongoing issues with communication between nursing and transportation staff, resulting in missed appointments. Further review showed no documentation that the resident attended the scheduled appointments or that transportation was arranged. The Director of Nursing and the Administrator confirmed that there was no evidence in the records of appointments being made or attended, and attempts to verify appointments with outside providers were unsuccessful. The facility's policy required assistance with arranging transportation, but this was not carried out as needed for the resident.
Failure to Provide Adequate Supervision and Maintain a Safe Environment
Penalty
Summary
The facility failed to provide adequate supervision and assistance for a resident who was dependent on two staff members for bathing. Despite care plan interventions specifying the need for two staff during all care, only one staff member was present when the resident experienced a leg spasm, fell from the bed, and sustained fractures in both legs. The staff member involved reported that she routinely provided care alone, as no one would assist her, and the resident confirmed that only one staff member was present during the incident. Facility leadership and documentation confirmed the resident's dependence on staff for all care and the expectation that care plans be followed. The facility also failed to ensure the environment was free from accident hazards for several residents. One resident was found to have a plugged-in electric coffee pot in their room, which was against facility policy due to the risk of burns or fire. Staff and leadership interviews confirmed that such appliances were not permitted, and the presence of the coffee pot had not been reported or addressed. Another resident had expired and unlabeled medications, including a bottle of nasal spray and a cup of white cream, left at the bedside without proper orders or assessment for self-administration. Staff acknowledged that medications should not be left at the bedside and that the resident did not have orders for self-administration. Additionally, a resident's room was observed to have a loose metal chair rail with sharp edges and splintered wood, creating a physical hazard. The maintenance director and DON confirmed that these conditions had not been reported and posed a risk of injury. The facility's failure to maintain a safe environment and to follow policies regarding supervision, medication administration, and environmental hazards resulted in actual harm and placed multiple residents at risk.
Failure to Provide Ordered Pain Medication Resulting in Actual Harm
Penalty
Summary
The facility failed to ensure that ordered pain medication, specifically methadone, was available for administration to a resident with chronic pain syndrome and opioid dependence. The resident missed multiple doses of methadone over several days due to issues with pharmacy dispensing, prescription diagnosis errors, and delays in obtaining new prescriptions or prior authorizations. Documentation showed that the resident missed a total of nine doses over three days, resulting in increased pain and withdrawal symptoms, which led the resident to call 911 and be transferred to the emergency room for treatment. Medical record review and staff interviews revealed that the resident had a history of chronic pain, recent surgeries, and opioid dependence, and was prescribed methadone three times daily. Despite this, there were repeated instances where the medication was not available due to the pharmacy's inability to fill prescriptions with an opioid dependence diagnosis, insurance issues, and delays in obtaining updated prescriptions from the provider. Staff interviews indicated inconsistent practices in reordering medications, lack of timely follow-up with the pharmacy or provider, and inadequate documentation regarding missed doses and communication with the provider. The facility's own policy required that pain medications be administered as ordered and that staff monitor for withdrawal symptoms and communicate with the provider if pain or side effects were not controlled. However, the resident experienced actual harm, including increased pain and withdrawal symptoms, due to the facility's failure to ensure the availability of methadone. The deficiency affected at least one resident and was substantiated by medical records, staff and resident interviews, and pharmacy documentation.
Failure to Protect Resident Health Information During Shift Reports
Penalty
Summary
Staff failed to maintain the confidentiality of residents' personal and medical records by conducting verbal shift reports in areas where other residents could overhear protected health information. Multiple residents with intact cognition reported overhearing details about other residents' diagnoses and medications during staff conversations at the nurses' station. One resident stated that she and others became aware of confidential medical information due to these discussions, and another resident, a former nurse, confirmed that she could hear health information during staff shift reports. A staff LPN acknowledged that shift reports were held at the nurses' station and admitted that residents could overhear protected health information, recognizing this as a HIPAA violation. The DON stated that private areas were available for such reports and did not expect staff to discuss confidential information within earshot of residents. Facility policy required staff-to-staff communication, such as shift reports, to be conducted outside the hearing range of residents and the public, but this was not followed, resulting in a breach of confidentiality for all residents in the facility.
Failure to Provide Required Abuse, Neglect, and Exploitation Training to Nursing Staff
Penalty
Summary
The facility failed to ensure that four nursing staff members received required training on abuse, neglect, and exploitation during orientation and annually, as mandated by facility policy. Employee file reviews showed that three nurses hired within the past two years had no documented evidence of having completed abuse/neglect training within the last 12 months. Additionally, a recently hired nurse had no documentation of receiving this training at all. These findings were confirmed through staff interviews, where the Director of Nursing, Administrator, and Human Resources Director all acknowledged the expectation that staff complete required in-services and that management should monitor compliance. However, the Human Resources Director was unable to explain why the required abuse training was missing for these staff members. The facility's policy on abuse prevention and reporting, updated in 2018, requires all new employees to receive training on abuse policies during orientation and mandates annual training for all staff. The policy specifies that training must cover definitions of abuse, neglect, and exploitation, reporting requirements, and appropriate interventions. The lack of documented training for these four nurses represents non-compliance with both facility policy and regulatory requirements, with the potential to affect all residents in the facility, which had a census of 92 at the time of the review.
Expired Medications and Inadequate Refrigerator Temperature Monitoring
Penalty
Summary
The facility failed to ensure expired medications were discarded and did not maintain proper monitoring of medication refrigerator temperatures. During observations, surveyors found 25 expired heparin lock flush solutions with expiration dates ranging from 03/2023 to 07/2022 in the medication room, as well as expired Solosite wound gel, enema saline laxative, and zinc oxide ointment on the medication cart. All expired items were unopened but accessible for use. Additionally, one medication refrigerator lacked a thermometer, and temperature logs for both medication refrigerators on two units showed significant gaps in daily monitoring and documentation, with several days and even weeks missing entries. Interviews with nursing staff and the DON revealed confusion and inconsistency regarding responsibility for checking medication refrigerators and monitoring for expired medications. The night shift was reportedly responsible for these tasks, but there was uncertainty about staff training and clear assignment of duties. Facility policy required nursing staff to maintain medication storage areas and to contact the pharmacy for instructions on handling outdated medications, but these procedures were not consistently followed, as evidenced by the presence of expired medications and incomplete temperature monitoring.
Infection Control Failures in Shower Room and Respiratory Equipment Storage
Penalty
Summary
Staff failed to maintain proper infection prevention and control practices in the facility's shower rooms and in the storage of respiratory equipment. Observations revealed that used towels were discarded on the shower room floor, and large bottles of shower supplies and hairbrushes were not designated for individual resident use. Multiple staff interviews confirmed that unlabeled personal care items were used by multiple residents, and staff were unsure of the ownership of certain items. Both the Director of Nursing and the Administrator acknowledged that each resident was expected to have their own labeled bath supplies, and that sharing such items posed an infection control concern. Additionally, the facility did not ensure proper storage of respiratory equipment for two residents with significant respiratory needs. One resident, in a persistent vegetative state with a tracheostomy and chronic respiratory failure, had a nebulizer machine and accessories left uncovered on the over-bed table between uses, rather than being stored in a plastic bag as required. Staff interviews confirmed knowledge of the correct storage procedure, but it was not followed due to oversight. The Director of Nursing and Administrator both stated that respiratory equipment should be covered when not in use. Another resident with COPD, asthma, and obstructive sleep apnea used a CPAP machine, but the CPAP mask was repeatedly observed lying uncovered on the resident's dresser rather than being stored in a plastic bag. Staff interviews confirmed that CPAP masks were expected to be stored in bags, but the facility did not have a formal policy for this practice. The Director of Nursing and Administrator both stated their expectation for proper storage, but this was not consistently implemented.
Damaged resident equipment left in use
Penalty
Summary
The facility failed to maintain resident equipment in good repair when Resident #3’s fall mat was observed torn across the middle with exposed foam and black stains. Resident #3 was admitted with altered mental status, muscle weakness, vascular dementia, syncope and collapse, and a history of falling, and a quarterly MDS assessment showed a BIMS score of 7, indicating severe cognitive impairment. The torn and stained mat was observed repeatedly in the resident’s room over several days, and CNA #31 stated it had been in that condition for the two weeks she had worked in the facility without being reported. RN #6 stated she noticed the mat and knew the resident needed a new one, but she had not requested replacement. CNA #19, who also served as the central supply manager, later replaced the mat and stated the prior mat was tattered and ripped and should have been replaced sooner. The facility also failed to maintain a shower bench in one shower room on the Willow Unit in good repair. During observation, the bench was noted to have cracked vinyl, exposed foam, and a worn, torn, and tattered surface. The Maintenance Director stated the cushion needed to be replaced but no one had reported the condition to him. An LPN stated she had not been notified and would not want to sit on the bench in its current condition. CNA #31 stated she had noticed the bench was worn and cracked for two years but had not personally reported it. The DON and Administrator stated they expected staff to report damaged equipment such as a torn shower bench, and the facility policy stated defective or worn devices are to be discarded or repaired.
IV hydration with micronutrients lacked documented medical necessity and proper provider credentials
Penalty
Summary
The facility failed to ensure IV therapy was administered in accordance with professional standards of practice and Ohio state requirements for residents receiving IV hydration with micronutrients through IV Therapy Company #1. The report states the facility did not establish, monitor, or document criteria showing medical necessity for the IV hydration with micronutrients, and it also failed to ensure the contracted ancillary provider had the appropriate Ohio-required credentials. This involved three residents reviewed for IV therapy services, with the practice potentially affecting additional current and discharged residents who received services from the same company. For one resident with anoxic brain damage, paraplegia, DM, CHF, and severe cognitive impairment, the record showed repeated monthly IV hydration and micronutrient infusions. The documentation included fluid intake summaries, urinary catheter output, and orders for normal saline with added vitamins and minerals, but the record did not include laboratory testing for the months reviewed and did not provide the requested physician order form for one month. Nursing notes documented peripheral IV insertions and completion of the infusions, while the IV Hydration Resident Risk Screening Tool and physician order forms were completed later and reflected broad indications such as low intake, functional impairment, depression, malnutrition risk, wounds, and difficulty communicating needs. Some sections of the screening tool were not signed or dated by nursing staff. For a second resident with paraplegia, chronic hepatitis C, and a stage 4 sacral pressure ulcer, the record showed IV hydration with supplemental micronutrients was ordered and administered through a PICC line and later through a peripheral IV. The resident’s documentation included meal fluid intake totals, but urinary catheter output was not monitored for some months and no comprehensive micronutrient panel was found in the laboratory results. One infusion attempt was interrupted when the IV site infiltrated, and a second attempt was unsuccessful. For a third resident with DM, hemiplegia, major depressive disorder, and epilepsy, the record showed IV hydration with micronutrients was ordered and administered through a peripheral IV, but the screening tool was not signed or dated by a nurse and the record did not include a comprehensive micronutrient panel. The report also states the contract with IV Therapy Company #1 did not match the company name on the Ohio Board of Pharmacy license, the company had not yet filed with the Ohio Secretary of State when the agreement was signed, and facility leaders and the NP described minimal involvement and limited knowledge of the program’s criteria and protocols.
IV Therapy Program Lacked Required Oversight and Compliant Procedures
Penalty
Summary
The facility failed to develop intravenous (IV) therapy procedures that were compliant with state requirements and accepted standards of practice for residents receiving IV medications from IV Therapy Company #1. The deficiency involved three residents reviewed in detail and was identified as affecting additional current and discharged residents who had received services from the company. Facility staff, including the DON, NP, and administrator, stated they had minimal knowledge of the program, did not know the criteria used to determine who should receive the treatments, and were not familiar with the company's policies or procedures. One resident had diagnoses including anoxic brain damage, paraplegia, diabetes mellitus, and CHF, and had severe cognitive impairment. The record showed repeated monthly IV hydration and micronutrient infusions with orders for normal saline plus multiple additives, including B-complex vitamins, vitamin C, biotin, zinc, and at times magnesium and calcium. The resident's IV hydration screening tools were not consistently signed or dated by nursing staff, and one month lacked the 72-hour post-monitoring order. The NP stated IV Therapy Company #1 had its own protocol and she was minimally involved, signing the monthly orders but not directing the process. A second resident had paraplegia, chronic hepatitis C, and a stage 4 sacral pressure ulcer. The record showed IV hydration with supplemental micronutrients through a PICC line, but the care plan did not include a focus area for participation in the IV Therapy Company #1 program. During one scheduled infusion, the resident's vein could not be accessed; during another, the peripheral IV infiltrated shortly after the infusion began and a second attempt was unsuccessful. A third resident had diabetes mellitus, hemiplegia, major depressive disorder, and epilepsy, and was also placed on the IV therapy program with orders for normal saline plus micronutrient additives. The resident's screening tool was not signed or dated by nursing staff, and the record showed the IV infusion was administered through a peripheral IV without the same post-monitoring order in September. The facility's contract with IV Therapy Company #1 was signed even though the company had not yet filed with the Ohio Secretary of State, and staff stated they were not aware of the company's licensure status or the details of the program.
Failure to Ensure Ongoing Communication with Dialysis Providers
Penalty
Summary
The facility failed to ensure ongoing communication with dialysis providers for two residents who required hemodialysis. Both residents had diagnoses including end stage renal disease and were receiving dialysis three times a week. Review of their medical records and care plans indicated that staff were directed to encourage attendance at dialysis appointments, but there was no documentation of communication between the facility and the dialysis center. Staff interviews revealed that information was not consistently sent with residents to the dialysis center, and when residents returned, the facility typically did not receive or review information from the dialysis center, except occasionally for laboratory work. Nurses reported that communication sheets were not being used regularly, and the dialysis center confirmed they had not received information from the facility for several months. The Director of Nursing stated that nurses were responsible for completing and sending dialysis communication sheets with residents for every treatment, and that returned sheets should be uploaded to the electronic medical record and placed in the paper chart. However, this process was not being followed, as evidenced by the lack of documentation and staff statements. Facility policy required arrangements with the contracted dialysis provider to include how information would be exchanged, but this was not occurring, resulting in a deficiency related to the management and communication of dialysis care for residents.
Failure to Administer Medications as Ordered Resulting in Significant Medication Errors
Penalty
Summary
The facility failed to ensure that medications were administered as ordered, resulting in significant medication errors affecting three of six residents reviewed. For one resident with a diagnosis of allergic rhinitis and severely impaired vision, a physician's order for prednisolone acetate eye drops was changed to be administered only in the right eye each morning following an optometrist visit. However, the medication administration records showed that staff continued to administer the drops in both eyes, and the new order was not transcribed or updated in the records. Interviews with nursing staff and the Director of Nursing confirmed that the order change was missed and not implemented as required. Another resident with chronic viral hepatitis C, opioid dependence, and HIV had a physician's order for quetiapine 50 mg to be administered nightly. Upon admission, the medication was incorrectly entered into the medication administration record to be given in the morning instead of at night. This error persisted for several days until the order was corrected. Staff interviews revealed that the error occurred due to oversight during the transcription of hospital orders, and there was no documentation of adverse effects during the period the medication was administered at the wrong time. A third resident with acute respiratory failure, ventricular tachycardia, and atherosclerotic heart disease had a physician's order for clopidogrel bisulfate (Plavix) 75 mg daily. The medication administration records indicated that the medication was not administered on several specified dates, with no documentation or physician notification regarding the missed doses. Staff interviews confirmed that the medication should not have been held without appropriate clinical justification or documentation. Facility policy required medications to be administered as prescribed and within the specified time frame, which was not followed in these cases.
Inaccurate MAR Documentation for Controlled Substance Administration
Penalty
Summary
The facility failed to ensure accurate documentation on the Medication Administration Record (MAR) for a resident with a history of chronic pain syndrome and opioid dependence. The resident was prescribed methadone three times daily for pain management. Review of the MAR for October and November revealed that methadone was signed as administered on several occasions, but there was no corresponding Controlled Drug Record (narcotic sheet) to indicate the medication was available or actually given on those dates and times. Interviews with nursing staff confirmed that they had signed the MAR indicating administration of methadone when, in fact, the medication was not given, attributing the errors to accidental documentation. The resident also reported that there were multiple instances when the facility was unable to obtain methadone from the pharmacy. Facility policy required that medications be administered as prescribed and that staff document administration accurately, including signing the MAR only after giving the medication. The Director of Nursing and the Administrator both confirmed that signing the MAR for medications not administered results in inaccurate medical records. The deficiency was identified through record review, staff and resident interviews, and policy review, and was investigated under a specific complaint number.
Failure to Notify Responsible Party of Tube Feeding Change
Penalty
Summary
The facility failed to ensure a resident’s responsible party was notified and approved of a change in treatment when the resident’s tube feeding regimen was changed from Fibersource HN at 60 to 65 mL/hr for 18 hours per day to Fibersource HN at 45 mL/hr continuously over 24 hours. Resident #6 had diagnoses including persistent vegetative state, severe protein-calorie malnutrition, and gastrostomy status, and was documented as tube-feeding dependent with no discernible consciousness. The resident’s care plan directed the RD to monitor intake and make recommendations for tube feeding changes as needed, and a dietary note stated the continuous feeding change was recommended for ease of administration and to provide the same nutrition as the prior regimen. There was no documentation that the resident’s responsible party was notified of the change in the tube feeding regimen. The responsible party stated they were not aware of any changes and said they would not have approved continuous tube feeding because the resident could not tolerate it. The DON stated an alternate dietitian recommended the continuous feeding change but did not communicate it to the responsible party, and the Administrator stated notifications should be made any time resident orders change. The facility policy required prompt notification of the resident, attending physician, and resident representative of changes in the resident’s medical or mental condition and/or status.
Failure to Provide ADL Hygiene Assistance
Penalty
Summary
The facility failed to provide ADL assistance for a dependent resident who required extensive to dependent help with hygiene and mobility. Resident #56 was admitted with diagnoses including legal blindness and multiple sclerosis, and a quarterly MDS assessment indicated intact cognition with a BIMS score of 15 and substantial/maximal assistance needed for personal hygiene. The care plan identified an ADL self-care deficit and directed staff to assist the resident with personal hygiene. An observation showed the resident had long, dirty fingernails, and the resident stated staff had not offered to trim or clean the fingernails or shave his facial hair after a bed bath. The resident said he wanted his fingernails cleaned and trimmed and his facial hair trimmed. CNA #12 stated the resident was dependent on staff for cleaning and trimming fingernails and shaving, and that staff should have asked the resident if he wanted these services during the bath but did not. CNA #12 and LPN #7 later observed and confirmed the resident's nails were dirty, jagged, and long and that he needed to be shaved. The DON and Administrator stated staff were expected to clean and trim fingernails and shave residents on shower or bath days or as needed, and the facility policy stated residents unable to perform ADLs independently are to receive services necessary to maintain grooming and personal hygiene.
Tube Feeding Not Given Per Physician Order
Penalty
Summary
The facility failed to ensure a resident's tube feeding was administered according to physician orders. Resident #06 was admitted with diagnoses including persistent vegetative state, severe protein-calorie malnutrition, and gastrostomy status, and the quarterly MDS indicated the resident had no discernible consciousness and received most calories and fluids through a feeding tube. The care plan identified the need for tube feeding related to chewing and swallowing problems, and the physician order recap showed an order for Fibersource HN at 45 mL/hr continuously over 24 hours. Observations showed the resident had no tube feeding hanging or infusing in the room on 12/18/25 in the morning and again at midday, and on 12/19/25 the resident was again observed without feeding infusing before the tube feeding was later found running at 60 mL/hr instead of the ordered 45 mL/hr. An RN stated he forgot to hang the feeding and had not read the orders or noticed the rate change, while an LPN stated she hung the feeding at noon based on an old schedule of 60 mL/hr from 12:00 P.M. to 6:00 A.M. and was not aware of any changes. The DON and Administrator stated tube feedings should be administered according to current orders, and the facility policy required nurses to confirm complete enteral nutrition orders including product, method, rate, and flushing instructions.
Failure to Maintain Oxygen Humidification
Penalty
Summary
The facility failed to provide respiratory care in accordance with physician's orders for one resident who had chronic respiratory failure with hypercapnia, chronic diastolic heart failure, COPD, shortness of breath, and morbid obesity with alveolar hypoventilation. The resident’s care plan directed nursing staff to provide supplemental oxygen as ordered. The physician’s order required supplemental oxygen with humidification at 2 to 3 LPM via nasal cannula as tolerated, later changed to 2 LPM with the option to titrate up to 3 LPM as tolerated. During multiple observations, the resident was receiving oxygen at 3 LPM via nasal cannula, but the humidifier bottle attached to the oxygen concentrator was dated 11/25 and was empty. The resident reported dryness in the nose and inside the nostrils during observations. Staff interviews reflected that humidifier bottles should be changed when empty, and one nurse stated they should be changed once a week and when empty to promote cleanliness and prevent dryness. The DON and Administrator stated the humidifiers should be changed appropriately and when empty. The facility policy required staff to check the humidifying jar, ensure there was water in it, and periodically re-check the water level.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to provide routine dental services for one resident who had been admitted with a history of traumatic subdural hemorrhage with loss of consciousness, cerebral infarction, and aphasia. The annual MDS showed the resident had moderate cognitive impairment, difficulty communicating, limited upper-extremity range of motion on one side, required supervision or touching assistance for oral hygiene, and had obvious or likely cavities and broken natural teeth. The care plan identified broken carious natural teeth and directed nursing staff and the social worker to coordinate dental care and transportation as needed, but the resident’s record contained no dental consultation order and no documentation of any dental appointment since admission. During observation, the resident was missing teeth and was unable to answer questions, though the resident was observed eating without difficulty and consumed about 75% of the meal. The MRD stated that if a resident could not request dental care, nursing could make the request, but the resident’s representative had to consent; the MRD also stated there was no documentation that the representative had been contacted regarding dental care and that no consultation report in the record meant the resident had not been seen by a dentist. The DON and Administrator stated residents should receive dental services at least once or twice a year and that consent refusals should be documented, but no such documentation was found.
Failure to Conduct Post-Fall Investigation
Penalty
Summary
The facility failed to conduct a post-fall investigation for a resident who was found unresponsive on the bathroom floor following an unwitnessed fall. Medical record review showed that the resident, admitted with diagnoses including congestive heart failure, chronic obstructive pulmonary disease, and schizoaffective disorder, did not have documentation of an investigation into the cause of the fall. Staff interviews with the DON, ED, ADON, and an RN confirmed that no post-fall investigation was completed, despite facility policy requiring staff to investigate falls to determine underlying causes and implement appropriate interventions. This deficiency was identified during a review of three residents for falls, with a facility census of 91 residents.
Failure to Notify Resident and Representative of Room Changes
Penalty
Summary
The facility failed to properly notify a resident and the resident’s representative of multiple room changes, as required. Medical record review for a resident with diagnoses including dementia, spinal stenosis, cervical spine injury, neuromuscular dysfunction, bipolar disorder, and a history of opioid and alcohol abuse, revealed that the resident was cognitively impaired and dependent on staff for activities of daily living. The resident experienced room changes on three separate occasions, but there was no documentation in the medical record regarding the reasons for these moves or evidence that the resident or their representative had been notified in writing prior to the changes. Interviews with the facility Administrator and Social Services Director confirmed the absence of documentation for both the reasons for the room changes and the required notifications. Additionally, the resident’s representative confirmed that she had not been informed of the room changes. This lack of notification and documentation was identified during a complaint investigation and affected one of three residents reviewed for room changes.
Failure to Monitor and Report Abnormal Blood Pressure Readings
Penalty
Summary
Facility staff failed to appropriately monitor and respond to abnormal blood pressure readings for a resident with chronic obstructive pulmonary disease, chronic kidney disease, and hypertension. Medical record review showed that on two separate occasions, the resident had significantly abnormal blood pressure readings—one low (91/40) and one high (203/99)—without documentation of a recheck or notification to a physician or provider. Interviews with staff revealed inconsistent practices regarding the rechecking of abnormal blood pressures and provider notification, with one LPN stating she only rechecks if time allows and does not notify providers, while an RN described a protocol of rechecking and notifying based on symptoms. The DON confirmed that staff are expected to recheck abnormal blood pressures within two hours and notify providers, regardless of symptoms. Further review of facility policy indicated that any blood pressure reading above 140/90 is considered hypertension and below 100/60 is hypotension, and that abnormal readings should be reported to a physician and documented at different times of the day. The physician interviewed confirmed that staff should recheck and notify providers if abnormal readings persist. The deficiency was identified during a complaint investigation and affected one resident out of 15 reviewed for blood pressure monitoring, with a facility census of 94 residents.
Failure to Prevent and Manage Pressure Ulcers Resulting in Actual Harm
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident with multiple risk factors, including diabetes mellitus type 2, cerebral infarction, vascular dementia, and major depressive disorder. The resident's care plan identified a high risk for skin breakdown due to impaired mobility, incontinence, and impaired cognition, with interventions such as barrier ointment, frequent weight shifting, nutritional monitoring, and a low-air loss mattress. Despite these interventions, there was no documentation of required weekly skin assessments for the entire month of January, and certified nursing assistant (CNA) documentation showed extensive gaps in turning and repositioning the resident as required. Further review revealed that when new wounds were identified on the resident's sacrum and left buttock, there were delays and inconsistencies in implementing and documenting physician-ordered wound care treatments. The Treatment Administration Record (TAR) showed missing or incomplete documentation for several days, and progress notes did not reflect the completion of wound care as ordered. Additionally, shower sheets were not accurately completed, failing to indicate the condition of the resident's skin. The lack of timely and thorough skin assessments and wound care allowed the resident's pressure ulcers to progress to advanced stages, including a stage IV ulcer and an unstageable ulcer. Interviews with facility staff, including the Director of Nursing (DON) and the Wound Nurse Practitioner (WNP), confirmed that required assessments and interventions were not completed as ordered. The WNP stated that the pressure ulcers were pressure-related and should have been avoided with proper turning, repositioning, and timely incontinence care. Facility policy and national guidelines emphasize the importance of regular skin assessments, prompt intervention, and thorough documentation, all of which were not followed in this case, resulting in actual harm to the resident.
Failure to Secure Resident's Electronic Medical Record
Penalty
Summary
A deficiency occurred when a registered nurse left a resident's electronic medical record (EMR) open and visible in a hallway while administering medications in the resident's room. The EMR contained private and confidential health information, which was accessible to other staff and residents passing by. The resident involved had diagnoses including diabetes mellitus type two, vascular dementia, and major depressive disorder, and was assessed as having moderate cognitive impairment. The facility's policy required that medical records be kept confidential and only disclosed to authorized persons with the resident's consent, but this policy was not followed in this instance.
Failure to Account for and Document Controlled Substance Administration
Penalty
Summary
The facility failed to ensure that controlled substances were properly accounted for and signed out after administration. During an observation, an LPN administered Lorazepam 0.5 mg and Modafinil 100 mg, both schedule IV controlled substances, to a resident without verifying the medication count prior to administration and without signing out the medications from the controlled substance log. The LPN confirmed in an interview that she did not check the controlled medication counts or document the administration in the controlled substance log as required. The resident involved had diagnoses including cerebral infarction, generalized anxiety disorder, peripheral vascular disease, and chronic respiratory failure, and required substantial assistance with activities of daily living. Facility policy required that medications, especially controlled substances, be prepared, administered, and recorded by the same licensed nurse, with documentation on both the medication administration record and the individual controlled substance record. These procedures were not followed during the observed medication pass.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required by regulation. During medication administration, a nurse did not provide two prescribed medications—Stress B/Zinc Oral tablet and Famotidine—to a resident because the medications were unavailable at the time of administration. This omission was confirmed by direct observation and staff interview. The affected resident had multiple diagnoses, including cerebral infarction, generalized anxiety disorder, peripheral vascular disease, gastroesophageal reflux disorder, and chronic respiratory failure, and required significant assistance with daily activities. A review of medication administration for four residents revealed that out of 26 medications administered by three nurses, two were omitted, resulting in a medication error rate of 7.7%. The facility's policy requires medications to be administered according to physician orders and outlines steps to be taken in the event of a medication error. The observed omissions and resulting error rate exceeded the acceptable threshold, constituting a deficiency as identified during the survey.
Infection Control Lapses During Medication Administration and Wound Care
Penalty
Summary
Surveyors identified multiple failures in infection prevention and control practices involving three residents. For one resident with diabetes, vascular dementia, and impaired mobility, a registered nurse assisted with wound care without donning an isolation gown, despite the resident being on Enhanced Barrier Precautions (EBP) due to chronic wounds. The facility's policy required the use of gowns and gloves during wound care for residents under EBP, but this protocol was not followed, as confirmed by the nurse during interview. In two other cases, medication administration practices did not adhere to infection control standards. One nurse administered medications by popping pills directly into his bare hands before placing them in a pill cup for a resident with moderate cognitive impairment. Another nurse picked up a dropped medication from the cart with a gloved hand and administered it to a resident with significant ADL dependence, then proceeded to administer medications to another resident without performing hand hygiene. These actions were inconsistent with the facility's hand hygiene policy, which requires hand cleaning before and after direct resident contact.
Failure to Ensure Safe and Orderly Discharge
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident, identified as Resident #90, who was admitted for surgical after-care following knee surgery and had a history of bipolar disorder and schizophrenia. The resident was initially discharged to a homeless shelter at the request of a caseworker, but the shelter refused to accept him due to his past behaviors, including setting fires. Consequently, the resident was returned to the facility and later discharged again to a hospital, which had previously discharged him, without a confirmed placement. The facility's management was unaware of the resident's violent incidents during his hospital stay prior to admission, as these were not communicated in the hospital notes shared with the facility. Despite the resident not exhibiting violent behaviors while at the facility, the caseworker insisted on discharging him due to his history. The facility did not provide a 30-day discharge notice or attempt to find alternative placement, relying instead on the caseworker's plan, which ultimately led to the resident being taken to multiple hospitals before being admitted. Interviews with facility staff and the caseworker manager revealed that the resident was improperly placed in the facility and that the caseworker should not have taken responsibility for the resident's discharge. The facility's policy on notice of transfer and discharge was not followed, as the resident was not given a 30-day notice, and the discharge was not conducted in a safe and orderly manner, as required by the policy.
Failure to Prevent and Treat Pressure Ulcers in Residents
Penalty
Summary
The facility failed to adequately assess and monitor the skin conditions of residents, leading to the development of avoidable, facility-acquired pressure ulcers. Resident #75, who was admitted without pressure ulcers but was at risk due to conditions such as dementia and diabetes, developed multiple stage III pressure ulcers on the right heel, right flank, and sacrum. Despite physician orders for interventions like heel protectors and a low air loss (LAL) mattress, these were not implemented in a timely manner, contributing to the progression of the ulcers. The facility's lack of a quick reference system for staff to access care interventions further exacerbated the issue. Resident #05, who was also admitted without pressure ulcers, developed a stage III pressure ulcer on the sacrum. The facility failed to notify the physician or document the skin breakdown in a timely manner, delaying appropriate treatment. The resident was at risk for pressure ulcers due to conditions such as a recent hip replacement and impaired mobility. Despite orders for a LAL mattress, it was not put in place until months after the ulcer was identified, indicating a significant lapse in implementing necessary preventive measures. Interviews with facility staff, including the Interim Director of Nursing and various nurses, revealed a lack of awareness and documentation regarding the necessary interventions for pressure ulcer prevention and treatment. The facility's policy on skin condition assessment and monitoring was not followed, as evidenced by the absence of weekly skin assessments and timely physician notifications. The facility's failure to implement physician-ordered interventions and conduct regular skin assessments resulted in the development and progression of pressure ulcers in residents who were initially admitted without such conditions.
Phone System Malfunction Affects Resident Communication
Penalty
Summary
The facility failed to maintain a functional phone system, which had the potential to affect all 84 residents residing in the facility. Observations from November 13 to November 19, 2024, revealed 15 unsuccessful attempts to reach facility personnel via the phone system. Each attempt resulted in a message stating, 'Hello, you have reached the ARC of Cincinnati. It is our pleasure to serve you today. Please leave a message and we will be happy to return your call as soon as possible. Thank you and have a good day.' There was no option to transfer to an individual, department, or nursing unit. The Administrator learned of the phone system's malfunction on November 17, 2024, and the Receptionist confirmed the issue had been ongoing since at least November 14, 2024, when a family member reported the inability to reach staff.
Failure to Serve Meals at Palatable Temperatures
Penalty
Summary
The facility failed to ensure that food was served at a warm and palatable temperature, affecting nearly all residents except two who did not receive food from the facility's kitchen. During an observation of the meal service, it was noted that the dinner meal, which included chili mac, cornbread, salad, green beans, and carrots, was initially prepared at appropriate temperatures. However, by the time the food was served to the residents, the temperatures had significantly dropped, with the chili mac at 96 degrees Fahrenheit, cornbread at 92 degrees Fahrenheit, and milk at 50 degrees Fahrenheit. The Dietary Manager confirmed these temperatures and acknowledged that the food was not hot and was bland in taste, with an unappealing presentation. Interviews with residents confirmed that their meals were cold and bland, corroborating the observations made by the surveyor and the Dietary Manager. The facility's policy on monitoring food temperatures, dated September 2023, was reviewed and indicated that food temperatures should be monitored to prevent foodborne illness and ensure palatable temperatures. Despite this policy, the deficiency was noted under Complaint Number OH00158984, highlighting a failure in the facility's food service process.
Environmental Deficiencies in Nursing Unit
Penalty
Summary
The facility failed to maintain a safe, functional, and homelike environment for its residents, affecting 23 individuals in the Fountains Nursing Unit. During an observation conducted on November 5, 2024, several deficiencies were noted. Resident #23's room had a significant area of damaged drywall with brown and black discoloration near the window. Additionally, the therapy gym and multiple common areas throughout the unit exhibited ceiling tiles with brown ring stains, indicating potential water damage. These observations were confirmed by the Maintenance Director, highlighting the facility's non-compliance with maintaining a suitable living environment.
Failure to Implement Policy on Injuries of Unknown Origin
Penalty
Summary
The facility failed to implement its policy regarding injuries of unknown origin when a resident was found with injuries. Resident #11, who had severe cognitive impairment and was dependent on staff for toileting and transfers, was found with scratches on her left eyebrow and cheek. The incident was initially documented by LPN #401, who notified the physician and family, and initiated an abuse/neglect screening. However, the documentation was later struck out by the Interim DON, who claimed the injury did not occur as described. The facility's Incidents and Accidents Log showed an entry for the injury, which was also struck out by the Interim DON. Despite the initial documentation and notifications made by LPN #401, the Interim DON and ADON #333 later stated that the injuries described in the progress notes were incorrect. The ADON, who assessed the resident with the previous Administrator, claimed there were no injuries as documented, but offered no further explanation or documentation to support this claim. The facility's policy required immediate reporting and investigation of any incident or suspicion of abuse, neglect, or injuries of unknown origin. However, the facility did not follow this policy when Resident #11 was found with injuries. The Interim DON's decision to strike out the documentation without a thorough investigation or explanation led to a deficiency in the facility's handling of the incident.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to timely report an injury of unknown origin involving a resident to the state agency. The resident, who had severe cognitive impairment and was dependent on staff for toileting and transfers, was found with scratches on her left cheek and eyebrow. These injuries were documented by an LPN, who also notified the physician and family, and initiated an abuse/neglect screening. However, the documentation was later struck out by the interim DON, who claimed the incident did not occur as described. The interim DON, who began employment after the incident, struck out all related documentation after being informed by the ADON that the injury did not happen. Despite the initial documentation by the LPN and witness statements from CNAs, the facility did not submit a Self-Reported Incident (SRI) to the state agency in a timely manner. The facility's policy required such incidents to be reported immediately, or within two hours if they involved abuse or serious bodily injury, and within 24 hours otherwise. Interviews with the LPN and CNAs confirmed the presence of the injuries on the resident, contradicting the interim DON and ADON's claims. The facility's failure to report the incident as per policy led to a deficiency being cited under a complaint investigation. The report highlights discrepancies in documentation and communication within the facility's administration regarding the incident.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown source involving a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease and repeated falls. The incident occurred when the resident was found in another resident's room with scratches on her left cheek and eyebrow. Despite the documentation of the injuries by an LPN and notifications made to the physician and family, the interim DON later struck out the documentation, claiming incorrect information. The interim DON, who started employment after the incident, was informed by the ADON that the injury did not occur, leading to the removal of the documentation. However, interviews with the LPN and CNA who discovered the resident confirmed the presence of the injuries. The facility's policy mandates a thorough investigation of any incident involving injuries of unknown origin, which was not adhered to in this case. The facility's incident log and self-reported incidents did not reflect a timely or thorough investigation of the resident's injuries. The interim DON and ADON's actions contradicted the initial findings and documentation by the LPN, resulting in a deficiency for failing to investigate the injury properly.
Failure to Administer Medications Timely Upon Admission
Penalty
Summary
The facility failed to ensure timely ordering and administration of medications for a resident upon admission. The resident, who was admitted with multiple diagnoses including malignant neoplasm of the lung, hepatic encephalopathy, and diabetes mellitus type II, did not receive physician-ordered medications on the evening of admission and the following morning. The medications included essential treatments such as rosuvastatin, melatonin, mirtazapine, olanzapine, omeprazole, and lactulose, which were not administered as per the physician's orders. The facility's Pyxis system had some of the medications available, yet they were not administered. The Interim Director of Nursing confirmed the oversight and acknowledged that the physician was not notified of the missed doses, nor were nursing notes or incident reports completed. The facility's policy requires immediate notification of the physician and documentation in the event of medication errors, which was not adhered to in this case. The consulting pharmacist indicated that a STAT order could have ensured timely delivery of the medications, but this was not done.
Inappropriate Use of Physical Restraint on Resident
Penalty
Summary
The facility failed to ensure a resident was free from physical restraints, which affected one resident with severe cognitive impairment and multiple medical conditions. The resident was admitted with diagnoses including cerebral infarction, brain stem stroke syndrome, dysphagia, cognitive communication deficit, and hemiplegia. The resident required maximal assistance with daily activities and had no orders for physical restraints or assessments completed for such use. On the day of the incident, the resident was observed being aggressive and attempting to get out of his wheelchair. In response, a State Tested Nurse Aide (STNA) tied a sheet around the resident's waist to prevent him from falling, which was not an appropriate or authorized restraint. The resident continued to exhibit combative behavior, and staff, including a Licensed Practical Nurse (LPN), were involved in trying to manage the situation. The incident was documented in progress notes and an incident report, and it was confirmed that the use of the sheet as a restraint was not ordered or assessed. Interviews with staff and observations confirmed that the resident was restrained with a sheet, which was against the facility's policy on physical restraints and abuse. The facility's Director of Nursing (DON) and other staff were notified of the incident, and it was determined that the restraint was inappropriate. The facility's policy review and personnel files indicated that the STNA involved had been educated on abuse and restraint policies but still used the sheet to restrain the resident.
Failure to Update Fall Care Plan with Current Interventions
Penalty
Summary
The facility failed to ensure a resident's fall care plan was updated with current interventions. This deficiency was identified during a review of Resident #01's chart, which revealed that the resident had severe cognitive impairment and required extensive assistance with various activities of daily living. Despite the resident being at risk for falls and requiring specific interventions such as a low bed and fall mats, these interventions were not documented in the resident's fall care plan. Observations confirmed that the resident was using a low bed and fall mats, but these were not reflected in the care plan. Interviews with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN) verified that the fall mat and low bed were not updated in the resident's fall care plan. The facility's policy on managing falls and fall risk, dated March 2018, mandates that staff identify interventions related to the resident's specific risks to prevent falls and minimize complications. The failure to update the care plan with current interventions represents non-compliance and was investigated under Complaint Number OH00152855.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Cincinnati
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Deupree Cottages | 0.1 mi | ★★★★★ | 0 | 0 |
| Marjorie P Lee Retirement Community | 1.9 mi | ★★★★★ | 9 | 0 |
| Pleasant Ridge Healthcare Center | 2 mi | ★★★★★ | 0 | 0 |
| Indianspring Of Oakley | 2 mi | ★★★★★ | 0 | 0 |
| St. Theresa Care Center | 2 mi | ★★★★★ | 3 | 0 |
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