Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Astoria Place Of Cincinnati during CMS and state inspections, most recent first.
Surveyors found that meals served did not match tray tickets or the posted menus. A resident with multiple medical conditions received a breakfast tray that differed from both the ticket and the planned menu when a cook failed to prepare a listed item. During lunch, residents were given additional sandwich toppings not on the menu, some residents later did not receive those toppings when the kitchen ran out, and all residents were served chocolate pudding instead of the chocolate cake specified on the menu, despite cake being available. These issues affected all residents receiving meals from the kitchen.
Surveyors found that meals, including pureed diets, were not prepared or served according to facility recipes or standards for palatability and temperature. The Dietary Manager blended chicken patties, lettuce, tomatoes, mayonnaise, and bread with hot water without using recipe cards, made gravy using only oil, flour, and water, and pureed rice with hot water instead of using cream of rice as specified. A test tray showed a cold chicken sandwich, bland broccoli without required lemon seasoning, and food items at non-appetizing temperatures. The RD confirmed staff should follow recipe cards and that the gravy formulation used would not taste good, and facility recipes and policy required more complete ingredients and palatable, well-balanced diets for all residents.
Surveyors found multiple failures to maintain sanitary food storage and preparation practices, including dirty soda equipment, a soiled cutting block, and dirty knives stored as clean. In the walk-in cooler and dry storage, various opened foods such as cheeses, bologna, pudding, pasta, and raw eggs were undated, and raw eggs were stored above other foods. The walk-in freezer was too warm, with food not fully frozen and an icicle from the condenser dripping over an open box of peas. The kitchen ice machine was leaking due to overfilling, and during a lunch meal service, broccoli on the steam table was held below the required hot-holding temperature because part of the steam table was not functioning, affecting all residents receiving meals.
Survey Results Notebook Not Updated: The facility failed to keep the most recent survey results and any plan of corrections readily accessible in the main receptionist area. The notebook still contained only older survey results, while CALS showed multiple later surveys that were not included. The Administrator confirmed the notebook had not been updated, and the facility policy stated residents have the right to examine survey results.
Incorrect Food Consistency for Residents on Modified Diets: The facility failed to serve foods in the correct consistency for residents on puree and mechanical soft diets. During lunch observation, residents on a mechanical soft diet were served regular broccoli instead of chopped bite-size broccoli, and residents on a puree diet were served rice pureed with water instead of cream of rice. The RD expected kitchen staff to follow the diet spreadsheets, and the DM verified the ordered consistencies were not provided.
The facility failed to complete a facility-wide assessment to determine the resources needed to care for residents competently during routine operations, nights and weekends, and emergencies. Review of QAPI documents showed no completed facility assessment on file, and the DON verified the assessment had not been completed. The deficiency affected all residents, with a census of 84.
Failure to Maintain an Ongoing QAPI Program: The facility failed to develop, implement, and maintain an effective QAPI program that identified and addressed systemic noncompliance, affecting all residents. Review of facility documents showed no documentation of any QAPI activities for all of 2025. The DON verified there was no QAPI Plan, no facility assessment, and no proof that QAPI meetings were held monthly and/or quarterly during that time.
Failure to Maintain QAPI Program Documentation: The facility's QAPI committee performed no QAPI activities for all of 2025, affecting all residents. Review of records found no QAPI Plan, facility assessment, performance improvement projects, or QAPI meeting minutes, and the DON confirmed the missing documentation. The facility policy stated the QAPI Plan should be ongoing and facility-wide to monitor and evaluate resident care quality and safety.
Failure to conduct required QAPI meetings: The facility had no documentation of monthly and/or quarterly QAPI meetings for all of 2025, affecting all residents. The DON verified the meetings were not held, and the facility policy stated the QAPI committee should meet monthly to review reports, evaluate data, and monitor quality-related activities.
Missing Legionella Water Management Program: The facility failed to ensure a comprehensive water management plan was implemented to reduce waterborne pathogens, including Legionella. Record review showed no water management plan was in place, and the DCO confirmed this during interview. The facility policy stated a water management program should be part of the IPC program, and CDC guidance outlined the multi-step process for developing and maintaining such a program.
Unsafe and Unsanitary Facility Conditions: Surveyors observed a large pool of water in the laundry area caused by a leaking pipe under a sink, with missing drywall and rusted studs in the adjacent wall. In the 400-hall dining area, a heating unit had an exposed wire, and in a resident’s room, a floor fan was covered with dust and pointed directly at the resident. The DON and RN confirmed the observed conditions, and the facility policy required a clean, sanitary, and orderly environment.
Failure to conduct required care conferences affected multiple residents. Records showed missing admission and quarterly care conferences for residents with diagnoses including CHF, CVA with hemiplegia, chronic respiratory failure with trach and vent, schizophrenia, Alzheimer's disease, and dementia. The DON and a resident representative confirmed that several conferences were not held or documented, and one resident had only a single conference with a legal guardian.
Expired influenza and pneumococcal vaccines were found in the medication storage room during a survey observation. The DON confirmed the vaccines were intended for residents in the 100 and 300 halls and acknowledged that expired vaccines were required to be removed and properly disposed of. Facility policy stated that outdated drugs or biologicals are returned to the dispensing pharmacy or destroyed.
Missing privacy curtains in multiple resident rooms prevented visual privacy during care. In one shared room, only one curtain was in place and staff confirmed it was not adequate for either resident; other shared rooms had no curtains at all, and staff and residents confirmed the curtains were missing, with one resident stating the curtains had not been present since admission. The facility policy stated residents had a right to privacy.
The facility did not maintain a safe, functional, and homelike environment when two cognitively intact residents sharing a semi-private room had a bathroom door that would not close completely, compromising privacy despite facility Resident Rights guaranteeing privacy. In a separate room, a resident with significant cognitive impairment and multiple medical conditions was found with an unmonitored portable space heater plugged in and running on the floor, even though facility policy prohibits portable space heaters. These conditions were inconsistent with the facility’s own policies requiring a safe, clean, comfortable, and homelike environment.
Plastic Utensils Provided Instead of Regular Utensils: Multiple residents were observed receiving meals with plastic utensils instead of regular metal utensils, and residents stated they disliked the plastic utensils and preferred regular utensils. Staff confirmed the kitchen periodically ran out of regular utensils because they were not returned in a timely manner, resulting in plastic utensils being used for meals.
A resident with CVA, aphasia, DM II, PTSD, HTN, and epilepsy was admitted to Hospice, but no significant change MDS assessment was completed when the resident transitioned to Hospice services. The DON verified the omission, and the resident’s MDS showed severe cognitive impairment and dependence for several ADLs.
A resident with paraplegia and neurogenic bladder was observed in the main lobby with his catheter bag sitting uncovered on his lap. The resident said he wanted a cover for the bag, and the DCO confirmed the bag was on his lap and not covered. Facility policy required residents to be treated with dignity and the urinary drainage bag to be held or positioned lower than the bladder at all times.
Failure to implement RD nutrition orders for a resident with significant weight loss. The resident, who had CHF, HTN, A-fib, bipolar disorder, and anxiety, lost weight over several months and the RD ordered double portions, diet liberalization, and weekly weights. However, the resident was not on the tray card for large/double portions, was not weighed weekly, and the DON and RD verified the interventions were not carried out.
A resident with cognitive impairment and multiple diagnoses reported verbal abuse by two CNAs. After the allegation was brought to the Administrator's attention, both staff members remained on duty and continued caring for residents, despite facility policy requiring immediate removal of accused employees pending investigation.
A resident with dementia and other medical conditions reported being sexually assaulted by a roommate, which was communicated to hospital staff and the facility's Director. Although the incident was discussed and a police report had previously been filed for similar allegations, the facility did not create a Self-Reported Incident (SRI) or ensure timely reporting to the state agency as required by policy.
A resident with dementia and other medical conditions reported to EMS and ER staff that he was fondled by his roommate. Despite the allegation and prior similar reports, facility staff did not initiate or document a required investigation or Self-Reported Incident (SRI), as confirmed by the Administrator. This failure was not in accordance with facility policy for abuse investigations.
A CNA did not change gloves or perform hand hygiene after providing incontinence care to a resident with severe cognitive impairment and urinary incontinence, instead applying a new incontinence brief immediately after cleaning the resident. This action was not in accordance with facility policy, which requires hand hygiene after contact with body fluids.
Surveyors found that an LPN had pre-pulled and stored loose pills for all residents on a unit in individual cups on the medication cart, rather than preparing and administering each resident's medication separately as required by facility policy. The DON confirmed this was not the correct procedure.
A resident with paraplegia and intact cognition was the subject of an unreported allegation of sexual abuse involving a staff member. Multiple staff reported the suspected relationship to the Administrator, but the facility did not notify the state agency until several months later, contrary to policy requiring reporting within 24 hours.
Two residents, one cognitively intact and one with mild cognitive deficits, had their cigarettes confiscated and discarded by the Administrator after being found smoking in a non-designated area. The cigarettes were not returned or replaced, constituting misappropriation of personal property as defined by facility policy.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A deficiency was cited when a resident was not protected from various forms of abuse and neglect, as the facility failed to ensure adequate safeguards against physical, mental, sexual abuse, physical punishment, and neglect by any individual.
A deficiency was cited when the facility did not provide a safe, clean, comfortable, and homelike environment, nor did it ensure that treatment and supports for daily living were delivered safely to residents.
Staff did not follow Enhanced Barrier Precautions (EBP) during incontinence and wound care for a resident with EBP orders. Observations showed that staff failed to don gowns and did not change gloves or perform hand hygiene after cleaning feces, then touched clean items. The DON and involved staff confirmed these infection control measures were not followed as required by facility policy and physician orders.
A resident with multiple complex medical conditions was subject to an emergency discharge after being accused by two other residents of possessing a firearm, though no weapon was found. The resident was denied re-entry, police were called, and the resident was discharged without a safe destination or arrangements for ongoing wound care. The resident's belongings were placed by the dumpster, and the individual left the property in a wheelchair without transportation or a coat, later spending two days in a car before being hospitalized.
A resident with a history of schizoaffective disorder, cognitive impairment, and exit-seeking behavior was not adequately supervised after expressing threats to leave and self-harm. Despite being placed on one-on-one supervision and later assessed as not suicidal, supervision was discontinued, and the care plan lacked specific interventions for elopement risk. The resident subsequently removed a windowpane, exited the building undetected, and sustained serious injuries after falling from a second-story window.
The facility did not inform residents of a lunch menu substitution when beef pot roast was replaced with hamburgers due to the pot roast not being ready. The dietary manager confirmed that no notification was provided to residents, contrary to facility policy, affecting all residents who received meals from the kitchen.
A resident with multiple health conditions was unable to control the temperature in their room due to a missing air conditioner knob and lack of instruction, resulting in discomfort. Additionally, several shower rooms were found to be unsanitary, with water damage, mildew, a non-functioning toilet, and feces on the floor, and these issues were not promptly reported or addressed by staff.
A resident with multiple chronic conditions and a history of falls suffered an unwitnessed fall resulting in a shoulder fracture. The LPN received the X-ray results but did not notify the physician directly, instead passing the information to the DON. The Medical Director was not made aware of the injury until two days later, delaying necessary evaluation and treatment, despite facility policy requiring immediate provider notification for significant injuries.
Two residents were involved in an incident where one resident with behavioral issues was struck and scratched by another resident with a history of aggression. Although the event was documented and investigated internally, it was not reported to the State Agency as required by facility policy, resulting in noncompliance.
A resident with multiple mental health diagnoses was admitted without documentation of a required PASRR screening. The social worker confirmed that PASRR screening should have occurred prior to admission, and facility policy required such screening for major mental disabilities before admission.
A resident with multiple medical and mental health diagnoses was not reassessed for PASRR after receiving new mental health diagnoses and being prescribed additional psychotropic medications. The social worker did not complete the required reassessment due to being unaware of these changes, despite facility policy requiring coordination of PASRR assessments after significant changes.
The facility did not consistently conduct quarterly care conferences with participation from the full interdisciplinary team for three residents with complex medical and psychiatric conditions. In some cases, care conferences were either not held, not documented, or conducted without the required team members or resident involvement, contrary to facility policy.
A resident with a history of falls and cognitive impairment suffered a shoulder injury after an unwitnessed fall. Despite X-ray confirmation of a fracture dislocation, staff did not promptly notify the physician or obtain timely treatment, resulting in a delay of care until the resident was eventually sent to the hospital two days later.
A resident with multiple psychiatric diagnoses did not attend a scheduled telemedicine mental health appointment because the clinical team failed to review the admission and communicate the appointment details, despite the information being present in the hospital paperwork. The oversight occurred when the ADON was assigned to the floor and the usual morning meeting did not take place.
Three residents did not receive medications as prescribed when an LPN borrowed medications from other residents to administer to a resident whose medications were unavailable, contrary to facility policy prohibiting such practice. The incident involved residents with complex medical conditions and was confirmed through record review and staff interview.
The facility failed to maintain accurate medical records for three residents, including incorrect discharge documentation for a resident with complex needs, lack of timely physician notification regarding a resident's fracture, and false documentation by an LPN about provider notification for discontinuation of one-to-one supervision. These actions did not meet the facility's policy for objective, complete, and accurate documentation.
The facility failed to maintain a sanitary kitchen environment, affecting 60 residents. Observations revealed issues such as debris from a floor fan, grease buildup on exhaust louvers, and mold in the dishwashing area. The ice machine had mold, and there was no temperature monitoring for the freezer and milk cooler. Foods were unlabeled, undated, and expired in resident refrigerators. The Dietary Manager confirmed these issues, which violated the facility's sanitation policy.
The facility failed to maintain a safe and comfortable environment for residents, with issues including vulgar writing on walls, excessively hot rooms without air-cooling equipment, and a poorly maintained smoke room. Residents experienced discomfort and inadequate living conditions, with no alternative accommodations or temperature monitoring provided.
The facility failed to provide visual privacy for residents, affecting several individuals on a secured women's unit. Observations showed incomplete privacy curtains and a lack of window blinds in some rooms. Interviews with staff and residents confirmed the need for adequate privacy measures, which were not in place, violating the facility's privacy policy.
The facility failed to provide a safe and sanitary environment for residents on the women's secured unit, affecting 19 residents. Observations revealed mold-like substances in the shower room, a non-operational exhaust fan, and a torn shower curtain compromising privacy. Additionally, a missing span of drywall in the chemical room and a leaking shower head in a storage room were noted. Staff confirmed these issues, and the facility's maintenance policy was reviewed.
A resident with multiple diagnoses, including dementia and anxiety disorder, was recommended eyeglasses by an optometrist, but the facility failed to ensure the order was completed. Despite being cognitively intact, the resident did not receive the eyeglasses, as confirmed by an LPN and a Social Worker Designee. Observations showed the resident squinting to read a clock, highlighting the deficiency in providing necessary vision services.
The facility did not submit the required PBJ staffing data to CMS for the first quarter of 2024. The omission was due to a contractor responsible for the submission not providing the necessary login credentials after his contract was terminated. The facility had to create a new profile to ensure future submissions.
Meals Served Did Not Match Posted Menus or Tray Tickets
Penalty
Summary
The deficiency involves the facility’s failure to ensure that meals served matched residents’ tray tickets and the posted menus, as required by facility policy. For one resident, admitted with diagnoses including COPD, history of TIA and cerebral infarction without residual deficits, left bundle-branch block, mood disorder, acute kidney failure, toxic encephalopathy, and cocaine abuse, surveyors observed a breakfast tray containing milk, grape juice, hot oatmeal, breakfast ham, and scrambled eggs. The tray ticket for this meal specified cold or hot cereal, juice of choice, waffles, breakfast ham, milk, and coffee or hot tea. The resident reported that tray tickets and menus often did not match the meals served, and confirmed that the breakfast provided did not match the ticket or menu that day. A CNA verified the discrepancy between the tray ticket and the items actually on the tray. The Dietary Manager confirmed that the written breakfast menu for that date included cold or hot cereal, juice of choice, waffles, breakfast ham slice, milk of choice, and coffee or hot tea, and stated that the cook forgot to make and serve the waffles listed on the menu. At lunch on the same date, the written menu indicated residents were to receive lemon zest broccoli, chocolate cake with icing, a chicken patty on a bun, and rice. During observation of lunch service with the Dietary Manager, residents’ trays were seen to include lettuce and tomatoes on their chicken patties, items not listed on the menu. Later in the meal service, the kitchen ran out of lettuce, and the Dietary Manager confirmed that 17 residents did not receive lettuce and tomatoes on their chicken sandwiches because the facility did not have enough of these items. Further observation showed that all residents received chocolate pudding instead of the chocolate cake with icing specified on the menu. The Dietary Manager verified that chocolate cake was available but a cook followed an incorrect menu and served chocolate pudding instead. Review of the facility’s “Menus” policy stated that menus are to be developed and prepared in advance to meet residents’ needs, but the observed meal service did not consistently follow the planned menus or tray tickets for all 84 residents receiving food from the kitchen.
Failure to Provide Palatable, Properly Prepared, and Appetizing-Temperature Meals
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was palatable, properly prepared according to recipes, and served at appetizing temperatures for all residents receiving meals from the kitchen. During lunch service, the posted menu included lemon zest broccoli, chocolate cake with icing, chicken patty on a bun, and rice. Observation of pureed diet preparation showed the Dietary Manager placing chicken patties, lettuce, tomatoes, mayonnaise, and slices of bread into a blender, then adding hot water to thin the mixture to a pudding-like consistency. The Dietary Manager acknowledged he did not use the facility’s recipe cards, relying instead on his own judgment of the desired consistency. He also prepared gravy for puree and mechanical soft diets using only oil, flour, and water, and prepared a rice puree by blending scoops of rice with hot water to a thick, sticky consistency. Review of the lunch spreadsheet showed that cream of rice should have been substituted for rice for residents on a puree diet. A test tray taken later that lunch period showed the chicken sandwich at 106°F, broccoli at 139°F, rice at 120°F, and chocolate pudding at 58°F. The surveyor tasted the items and found the broccoli bland and the chicken sandwich cold; the Dietary Manager confirmed the chicken sandwich was cold and that lemon seasoning, which should have been added to the broccoli, was missing. The Registered Dietician stated that kitchen staff should follow recipe cards and spreadsheets and verified that gravy made only with oil, flour, and water would not taste very good, noting that a chicken or beef base would be expected for flavoring. Review of the facility’s recipe cards showed that the chicken patty on bun for puree diets should have the meat, mayonnaise, and bread pureed together, with gravy added gradually to achieve a smooth consistency, and that gravy should be made with flour, fat from meat drippings, black pepper, chicken or beef base, and water. The facility’s Food and Nutrition Services policy stated that each resident is to be provided a nourishing, palatable, well-balanced diet that meets daily nutritional and special dietary needs.
Unsanitary Food Storage, Preparation, and Temperature Control in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to store and prepare food in a sanitary manner consistent with its own policies and professional standards. During kitchen observation, the soda gun nozzle was found dirty with a red buildup, and a white cutting block attached to the steam table had black residue on its surface. In the food prep area, five dirty knives were stored in a case designated for clean knives. The Dietary Manager confirmed each of these items was dirty despite facility policies stating that all kitchen equipment, counters, and utensils should be kept clean. Additional observations showed multiple food storage and temperature control issues. In the walk-in cooler, vanilla pudding, several types of cheese, bologna, and opened raw eggs were undated, and the raw eggs were stored on the top shelf above potatoes, contrary to policy requiring food to be dated and raw eggs to be stored on the bottom shelf. The walk-in freezer registered 25°F, and food inside was soft rather than frozen solid, despite policy requiring frozen food to be maintained in a solid state; an icicle was also observed hanging from the condenser above an open box of peas. In dry storage, opened bags of spaghetti and egg noodles were undated. The ice machine in the kitchen was leaking due to overfilling, and during a lunch meal service, broccoli on the steam table was held at 123°F while part of the steam table was not working, even though facility policy required hot foods to be held above 135°F. These conditions had the potential to affect all 84 residents in the facility.
Survey Results Notebook Not Updated
Penalty
Summary
The facility failed to maintain the most recent survey of the facility conducted by Federal or State surveyors and any plan of corrections in a readily accessible location for residents. Review of the survey results notebook in the main receptionist area showed the last survey results were dated 08/16/23, while review of the Certification and Licensure System showed multiple later surveys conducted on 08/31/23, 09/21/23, 10/24/23, 11/08/23, 12/26/23, 01/23/24, 02/22/24, 03/13/24, 04/09/24, 04/18/24, 06/12/24, 08/12/24, 09/19/24, 10/02/24, 10/22/24, 12/24/24, 05/19/25, 07/10/25, 07/18/25, 08/12/25, 10/22/25, 12/09/25, and 01/22/26 that were not included in the notebook. During interview, the Administrator confirmed the survey results notebook had not been updated since 08/16/23. The facility policy titled Resident Rights stated employees shall treat all residents with kindness, respect, and dignity and that residents have the right to examine survey results.
Incorrect Food Consistency for Residents on Modified Diets
Penalty
Summary
The facility failed to ensure foods were prepared in the correct consistency for residents with puree and mechanical soft diet orders. Three residents had physician orders for a puree diet, and fourteen residents had physician orders for a mechanical soft diet. The lunch menu for 02/18/26 included lemon zest broccoli, chocolate cake with icing, chicken patty on bun, and rice, and the lunch spreadsheet indicated residents on a mechanical soft diet should receive chopped bite-size broccoli while residents on a puree diet should receive cream of rice. During observation of the lunch service on 02/18/26 at 11:57 A.M., residents ordered a mechanical soft diet were served the same broccoli as the regular diets, and residents ordered a puree diet were served rice pureed with water. The RD stated he would expect kitchen staff to follow the items listed on the spreadsheets. The DM verified the spreadsheet indicated mechanical soft residents should have received cut broccoli and puree residents should have been served cream of rice, and also verified the residents were not served cut broccoli and cream of rice. The facility policy stated each resident is provided a nourishing, palatable well-balanced diet that meets his or her daily nutritional and special dietary needs.
Failure to Complete Facility Assessment
Penalty
Summary
The facility failed to complete a facility-wide assessment to determine what resources were necessary to care for residents competently during day-to-day operations, including nights and weekends, and during emergencies. Review of the facility QAPI documents showed there was no completed facility assessment document on file. During an interview on 02/10/26 at 5:48 P.M., the DON verified that the facility had not completed a facility assessment. Review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) Plan dated 2001 showed the facility should develop, implement, and maintain an ongoing, facility-wide QAPI Plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality, and resolve identified problems. The deficiency affected all residents in the facility, and the census was 84 residents.
Failure to Maintain an Ongoing QAPI Program
Penalty
Summary
The facility failed to develop, implement, and maintain an effective QAPI program that identified and addressed systemic noncompliance, affecting all residents in the facility with a census of 84. Review of facility documents showed there was no documentation of any facility QAPI activities for the entirety of 2025. During interview on 02/10/26 at 5:48 P.M., the DON verified the facility did not have any QAPI activities for the entirety of 2025, including no QAPI Plan, no facility assessment, and no proof that QAPI meetings were held monthly and/or quarterly during 2025. Review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) Plan, dated 2001, stated the facility should develop, implement, and maintain an ongoing, facility-wide QAPI Plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality, and resolve identified problems.
Failure to Maintain QAPI Program Documentation
Penalty
Summary
The facility's QAPI committee failed to perform any QAPI activities for the entirety of 2025, affecting all residents in the facility, with a census of 84 residents. Review of facility documents showed no documentation of a QAPI Plan, a facility assessment, performance improvement projects, or QAPI meeting minutes for all of 2025. During an interview on 02/10/26 at 5:48 P.M., the DON verified that the facility did not have documentation of a QAPI Plan, a facility assessment, performance improvement projects, or QAPI meeting minutes for the entirety of 2025. Review of the policy titled, Quality Assurance and Performance Improvement (QAPI) Plan, dated 2001, stated the facility should develop, implement, and maintain an ongoing facility-wide QAPI Plan to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality, and resolve identified problems.
Failure to Conduct Required QAPI Meetings
Penalty
Summary
The facility failed to ensure Quality Assurance and Performance Improvement (QAPI) meetings were conducted on a quarterly basis, affecting all residents in the facility, with a census of 84 residents. Review of facility documents showed there was no documentation of QAPI meetings conducted monthly and/or quarterly for the entirety of 2025. During interview on 02/10/26 at 5:48 P.M., the DON verified that the facility did not conduct monthly and/or quarterly QAPI meetings for the entirety of 2025. Review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) Plan, dated 2001, stated the QAPI committee should meet monthly to review reports, evaluate the significance of data, and monitor quality-related activities of all departments, services, or committees.
Missing Legionella Water Management Program
Penalty
Summary
Provide and implement an infection prevention and control program. Based on record review, staff interview, review of the facility policy, and review of online CDC resources, the facility failed to ensure a comprehensive water management plan was implemented to minimize the risk of waterborne pathogens including Legionella. Review of facility documents revealed the facility did not have a water management plan to prevent the growth of Legionella. During interview, the Director of Clinical Operations confirmed the facility did not have a water management plan in place to prevent the growth of Legionella. Review of the facility policy titled Legionella Water Management Program, undated, stated that the facility would have a water management program in place as part of the infection prevention and control program. Review of CDC guidance titled Steps to Develop a Water Management Program described a multi-step process requiring continuous review, including establishing a team, describing building water systems, identifying areas where Legionella could grow and spread, deciding where to apply and monitor control measures, establishing interventions when control limits are not met, ensuring the program runs as designed and is effective, and documenting and communicating all activities.
Unsafe and Unsanitary Facility Conditions
Penalty
Summary
The facility failed to maintain the building in a safe and sanitary manner for residents, staff, and the public. In the laundry area, surveyors observed a pool of water on the floor directly inside the entrance to the dirty linens area that measured approximately three feet by six feet and about one-eighth inch deep. Water was actively being released from a pipe under a sink next to the pooled water, and the wall beside the water had about two inches of missing drywall at the bottom with rusted metal studs visible. Laundry Aides confirmed the water was present at the entrance used to bring dirty linens into the area, and the Maintenance Director confirmed the leak and stated he had been aware of the leaking pipe since his first day of employment. In the 400-hall dining area, surveyors observed a heating unit that was uncovered with a wire sticking out from the left side, and the unit’s cover was on the floor. On a later observation, the heating unit was covered, but a wire was still sticking out from the left side. The DON confirmed the wire remained exposed and identified it as a safety hazard for the residents on 400 hall, who were mobile and ate their meals in the dining area. In Resident #7’s room, a square floor fan was observed with a white grate covered in black dust particles, some approximately two inches long, while the fan was on and pointed directly at the resident. RN #305 confirmed the fan was dusty and positioned toward the resident. The facility policy titled Quality of Life – Homelike Environment stated that staff and management would maintain a clean, sanitary, and orderly environment.
Failure to Conduct Required Care Conferences
Penalty
Summary
The facility failed to conduct quarterly care conferences and admission care conferences for multiple residents whose records were reviewed. Resident #03 was admitted with diagnoses including congestive heart failure, hypertension, atrial fibrillation, bipolar disorder, and anxiety disorder, and the MDS quarterly assessment showed intact cognition. The only documented care conference for this resident was in the third quarter of 2025, with no documented admission conference or fourth quarter conference. The DON verified that Resident #03 did not receive an admission care conference or a fourth quarter 2025 care conference. Resident #06 was admitted with diagnoses including CVA with left-sided hemiplegia and hemiparesis, dysphagia, CHF, and depression, and the admission MDS showed moderate cognitive impairment; no admission care conference was documented, and the resident's representative stated there had been no communication about the plan of care. Resident #07, admitted with chronic respiratory failure with hypoxia, tracheostomy, mechanical ventilation, dysphagia, enteral feeding tube, diabetes mellitus type II, atrial fibrillation, and depression, had intact cognition on the quarterly MDS, but no care conferences were documented in any quarter of 2025. Resident #61, admitted with schizophrenia, COPD, Alzheimer's disease, PVD, bipolar disorder, and anxiety disorder, had moderate cognitive impairment on the quarterly MDS; only a third quarter 2025 conference was documented, with none in the first, second, or fourth quarters. Resident #49, admitted with hemiplegia and hemiparesis following cerebral infarction, type II diabetes mellitus, anxiety disorder, polyneuropathy, muscle weakness, major depressive disorder, and alcohol use with alcohol-induced persisting dementia, had severe problems with thinking and memory and was dependent or maximal assistance for multiple ADLs; only one care conference with the legal guardian was documented, and no additional conferences were found.
Expired Vaccines Found in Medication Storage
Penalty
Summary
Drugs and biologicals in the facility were not properly managed because expired vaccines were found in the medication storage room. During a medication storage observation, three 0.5 mL single-dose Influenza Vaccine Afluria syringes were observed with an expired date, and four boxes containing ten Pneumococcal Vaccine Polyvalent Pneumovax-23 single-dose 0.5 mL syringes each were also found expired. The Director of Nursing confirmed that the products in the first-floor medication storage room were intended for residents in the 100 and 300 halls and acknowledged that staff were required to remove and properly dispose of expired vaccines. Review of the facility policy on Storage of Medications stated that discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.
Missing Privacy Curtains in Resident Rooms
Penalty
Summary
The facility failed to provide privacy curtains in resident rooms, affecting five residents reviewed for privacy in a census of 84 residents. In the room shared by Residents #96 and #30, only one privacy curtain was present and staff confirmed it was not adequate to provide visual privacy to either resident during care. The same room continued to have only one privacy curtain on later observations. No privacy curtains were observed in Resident #18's room, and an RN confirmed the curtains were missing and was unsure how long they had been absent. No privacy curtains were present in Resident #10's room, which had a roommate, and the resident confirmed the curtains were not present. No privacy curtains were present in Resident #80's room, which also had a roommate; the resident stated there had been no privacy curtains in the room since admission, and HR confirmed the curtains were not present and could not confirm how long they had been missing. The facility policy titled Resident Rights stated residents had a right to privacy.
Failure to Maintain Resident Privacy and Safe Environmental Conditions
Penalty
Summary
The facility failed to ensure a safe, functional, and homelike environment by not maintaining resident privacy and by allowing the use of prohibited electrical equipment. For two cognitively intact residents sharing a semi-private room, surveyors observed that the shared bathroom door did not close completely, which did not provide adequate privacy while using the bathroom adjacent to their sleeping quarters. Both residents expressed concerns that the bathroom door’s inability to close fully did not provide enough privacy for either of them. A Human Resources staff member confirmed that the bathroom door adjacent to each resident’s sleeping quarters did not close completely. Facility documentation on Resident Rights stated that residents are guaranteed rights to privacy under Federal and State laws. In another room, a resident with severe problems with thinking and memory, and diagnoses including hemiplegia following cerebral infarction, type II diabetes mellitus, anxiety disorder, polyneuropathy, muscle weakness, major depressive disorder, and alcohol-induced persisting dementia, was found with an unmonitored portable space heater plugged in and running on the floor, with the room door standing open. A CNA verified that the space heater was running in the resident’s room, and the DON stated that the heater was being used because the room’s heat was not working properly. Review of the facility’s Electrical Safety for Residents policy, revised January 2011, stated that portable space heaters are not permitted in the facility. The facility’s Quality of Life–Homelike Environment policy stated that residents are to be provided with a safe, clean, comfortable, and homelike environment, including a clean, sanitary, and orderly environment.
Plastic Utensils Provided Instead of Regular Utensils
Penalty
Summary
The facility failed to provide residents with regular utensils during meals and instead served plastic utensils to residents who preferred metal utensils. Resident #37, admitted with diagnoses including COPD, prior TIA, cerebral infarction without residual deficits, left bundle-branch block, mood disorder, acute kidney failure, toxic encephalopathy, and cocaine abuse, was observed eating breakfast with plastic utensils in her room and stated she was displeased with being provided plastic utensils and would prefer regular utensils. A CNA confirmed she was given plastic utensils because the kitchen periodically ran out of regular utensils, and another CNA stated regular utensils were not often returned to the kitchen in a timely manner, causing shortages. Resident #03, who had diagnoses including CHF, HTN, atrial fibrillation, bipolar disorder, and anxiety disorder and required set-up assistance for eating, was observed with a breakfast tray delivered with plastic utensils and stated he disliked them and preferred regular utensils. Resident #61, who had diagnoses including schizophrenia, COPD, Alzheimer's disease, peripheral vascular disease, bipolar disorder, and anxiety disorder and was independent for eating, was also observed with a breakfast tray delivered with plastic utensils and stated he disliked them and preferred regular utensils. The facility document on Quality of Life and a homelike environment stated staff and management shall maximize characteristics that reflect a personalized, homelike setting.
Failure to Complete Significant Change Assessment After Hospice Transition
Penalty
Summary
The facility failed to complete a significant change assessment for Resident #02 when the resident transitioned to Hospice services. Resident #02 was admitted with diagnoses including cerebral vascular accident with aphasia, diabetes mellitus type II, post-traumatic stress disorder, hypertension, and epilepsy, and the most recent MDS quarterly assessment showed severe cognitive impairment, frequent bowel incontinence, occasional bladder incontinence, and dependence on staff for several activities of daily living. A Hospice progress note documented that the resident was admitted to Hospice services for a diagnosis of cerebral vascular accident, and a physician order was written for Hospice admission. Review of the MDS assessments showed that no significant change assessment was completed for the resident’s transition to Hospice, and the DON verified this during interview.
Uncovered Catheter Bag in Main Lobby
Penalty
Summary
The facility failed to provide a discreet cover for a resident's catheter bag and failed to ensure appropriate placement of the catheter bag. Resident #94 was admitted with diagnoses including acute hematogenous osteomyelitis of the left ankle and foot, complete lesion at T1 level of the thoracic spinal cord, neuromuscular dysfunction of the bladder, paraplegia, schizoaffective disorder, and acquired absence of the right leg above the knee. The admission MDS was still in progress, and a BIMS showed the resident was cognitively intact. On observation, Resident #94 was in the main lobby with the catheter bag sitting on his lap and not covered. During interview, the resident acknowledged the catheter bag was lying on his lap uncovered and stated he would like to have a cover for it. The DCO confirmed the catheter bag was on the resident's lap and not covered while he was present in the main lobby. Facility policy stated employees shall treat residents with kindness, respect, and dignity, and the urinary drainage bag must be held or positioned lower than the bladder at all times.
Failure to Implement RD Nutrition Orders for Resident Weight Loss
Penalty
Summary
The facility failed to implement the Registered Dietitian’s nutritional recommendations for Resident #03, who had diagnoses including congestive heart failure, hypertension, atrial fibrillation, bipolar disorder, and anxiety disorder. The resident’s weights showed a 14.12% loss over six months, with continued loss over three months as well. The RD documented that the resident had been ordered double portions for all meals, later identified significant weight loss, and on 12/11/25 recommended liberalizing the diet from No Added Salt to regular to improve palatability and intake, along with weekly weights if the loss was confirmed. A physician order was entered for a regular diet on 12/12/25. Despite the RD’s later note on 01/15/26 stating the resident should resume large portions with meals and have weekly weights, the resident was not placed on the list to receive large or double portions and was not weighed weekly. The resident stated he was not trying to lose weight and was not receiving double portions. Observation of the breakfast tray showed food provided did not match the menu, and the menu tray card did not indicate large or double portions. The DON and RD both verified that the recommendations for large/double portions and weekly weights had not been implemented, and the DON also verified there were no documented weights from 12/24/25 to 02/01/26.
Failure to Remove Staff Accused of Abuse Pending Investigation
Penalty
Summary
The facility failed to follow its abuse policy in response to an allegation of verbal abuse by staff towards a resident. The resident, who had a history of diffuse traumatic brain injury, vascular dementia, mood disorder, and major depressive disorder, reported being verbally abused by two CNAs. The resident had moderate cognitive impairment and was independent with activities of daily living. The incident was not reported by the resident at the time it occurred. Upon being informed of the allegation by a surveyor, the Administrator acknowledged not being previously aware of the abuse claim. Despite the facility's policy requiring immediate removal of staff accused of abuse pending investigation, both CNAs remained on duty and continued caring for residents after the allegation was reported. Review of time sheets confirmed that the accused staff members were present and working during this period, contrary to facility policy.
Failure to Timely Report Alleged Sexual Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident to the state agency as required by policy. The incident involved a resident with dementia, type II diabetes mellitus, and bipolar disorder, who was admitted to the emergency room after EMS was called for a hyperglycemic event. During the EMS response, the resident reported that his roommate had fondled him in the bathroom. The hospital social worker communicated with the facility's Director, who acknowledged that the resident was more distraught than usual and that similar allegations had previously been made against the same roommate, with a police report already filed. Despite these events, a review of the facility's Self-Reported Incidents (SRI) revealed that no SRI was created for the alleged sexual abuse. The Administrator stated that he had sent an email to the Ohio Department of Health to report the issue but did not follow up after receiving no response, and confirmed that no SRI was filed. Facility policy requires that all allegations of abuse, neglect, exploitation, or mistreatment be reported immediately, but no later than two hours after the allegation is made, to the State Agency.
Failure to Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged sexual abuse incident involving a resident with dementia, type II diabetes mellitus, and bipolar disorder. The resident was admitted to the emergency room after EMS was called for a hyperglycemic event, during which the resident reported to EMS that his roommate had fondled him in the bathroom. The ER records indicated that the resident was visibly distressed, and the facility Director acknowledged that similar allegations had previously been made against the same roommate, with a police report already filed. Despite these circumstances, the facility did not initiate or document a Self-Reported Incident (SRI) for this allegation. A review of facility records confirmed that no investigation was conducted regarding the reported sexual abuse. The Administrator verified that there was no documentation or evidence of an investigation into the incident. Facility policy requires immediate initiation of an investigation into any abuse allegations, including a root cause analysis and cooperation from all staff to ensure resident protection. However, these procedures were not followed in this case, resulting in non-compliance with the facility's abuse investigation policy.
Failure to Follow Hand Hygiene Protocol During Incontinence Care
Penalty
Summary
During a review of infection control practices, it was observed that a certified nursing assistant (CNA) failed to follow proper hand hygiene protocols while providing incontinence care to a resident with severe cognitive impairment and functional urinary incontinence. After cleaning the resident and removing a soiled incontinence brief, the CNA did not change gloves or perform hand hygiene before applying a new brief. This was confirmed during an interview with the CNA, who acknowledged not changing gloves or performing hand hygiene after contact with urine. Facility policy requires hand hygiene with soap and water when hands are visibly soiled or contaminated with body fluids, in accordance with CDC and WHO standards.
Improper Pre-Pulling and Storage of Medications on Medication Cart
Penalty
Summary
Surveyors observed that the medication cart on the 200-unit contained 18 cups of loose pills, each labeled with the names of all residents on the unit. An LPN confirmed that she had pre-pulled all morning medications for these residents in advance of administration. The DON verified that this practice was not in accordance with facility policy, which requires medications to be prepared, administered, and signed off for each resident individually before proceeding to the next. The facility's policy also specifies that the person administering medications should initial the Medication Administration Record (MAR) after giving each resident's medication and before administering the next.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident with paraplegia and intact cognition in a timely manner to the Ohio Department of Health. The resident was admitted in early January and discharged in early April. Multiple staff members, including a staff member and a social worker, reported to the previous Administrator in early April that there was a suspected sexual relationship between the Housekeeping Supervisor and the resident. Despite these reports, the allegation was not reported to the state agency until mid-October, several months after the resident had been discharged. Interviews with facility staff and review of the facility's Self-Reported Incidents (SRIs) confirmed that the required notification to authorities did not occur within the 24-hour timeframe outlined in the facility's Abuse and Neglect Protocol. The facility's investigation, initiated only after the delayed report, did not substantiate the abuse. The deficiency centers on the facility's failure to promptly report the allegation as required by policy and regulation.
Misappropriation of Residents' Personal Property by Administrator
Penalty
Summary
The facility failed to prevent the misappropriation of residents' personal property, specifically cigarettes, for two residents. One resident, who was cognitively intact and independent with activities of daily living, and another resident, who had mild cognitive deficits and required extensive staff assistance, were both found smoking in a non-designated area outside the facility. The Administrator observed the residents smoking in this area and, after informing them that smoking was not permitted there, confiscated their cigarettes and disposed of them in the garbage. The Administrator did not return or replace the cigarettes for either resident. Interviews with both residents confirmed that their cigarettes were taken and discarded by the Administrator after being found smoking in a non-designated area. The facility's policy defines misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. The Administrator acknowledged taking and discarding the cigarettes and confirmed that the items were not replaced, which constituted a failure to protect residents from the wrongful use of their belongings.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's protective measures and oversight.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that the facility did not ensure residents received treatment and supports for daily living in a manner that maintained their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Staff failed to implement Enhanced Barrier Precautions (EBP) during incontinence and wound care for a resident with orders for EBP. Observations revealed that staff did not don gowns prior to providing incontinence care and wound care, despite signage and physician orders indicating the need for EBP. During incontinence care, a certified nursing assistant (CNA) cleansed feces from the resident's buttocks but did not remove gloves, perform hand hygiene, or don new gloves before proceeding to touch clean items such as the resident's brief, pajama bottoms, sheets, and wash basin. The same lack of gown use was observed during wound care. The resident involved had diagnoses including dementia, hypertension, and chronic kidney disease, and was frequently incontinent of bowel and occasionally incontinent of bladder. The resident required varying levels of assistance with personal care activities. Interviews with the staff involved and the Director of Nursing confirmed that the required infection control measures, including donning gowns and changing gloves with appropriate hand hygiene, were not followed as per facility policy and physician orders.
Failure to Provide Safe and Orderly Discharge for Resident
Penalty
Summary
The facility failed to provide a safe and orderly discharge for a resident who was subject to an emergency discharge following allegations from two other residents that the individual possessed a firearm and had made threats. The resident, who had diagnoses including unspecified paraplegia, a stage III pressure ulcer, chronic pain syndrome, malnutrition, morbid obesity, bipolar disorder, and neuromuscular bladder dysfunction, left the facility without signing out and was later refused re-entry. Despite multiple attempts by the social worker to secure alternative placement and community resources, no emergency housing or LTC facility would accept the resident, and the resident was unavailable to participate in discharge planning. When the resident returned to the facility, staff, following instructions from administration and police, did not allow entry and called law enforcement. Police searched the resident and found no weapon. The resident was given discharge paperwork, a face sheet, a medication list, and routine medications (excluding narcotics), but was not provided with a safe discharge destination or arrangements for ongoing wound care. The resident's belongings were packed in trash bags and placed by the dumpster, and the resident left the property in a wheelchair without a coat or transportation, ultimately spending two days in a car before being hospitalized for a stomach infection. Interviews with staff, the Ombudsman, and police confirmed that the resident was discharged without a safe destination, and that the facility's discharge notice inaccurately listed a destination. The resident did not take any belongings with him, and staff were unclear about his whereabouts after leaving. The facility's own policy required advance preparation for discharge, including assistance with transportation and ensuring a safe discharge location, but these steps were not followed in this case.
Failure to Prevent Elopement Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident, identified as an elopement risk with a history of schizoaffective disorder, suicidal ideation, substance abuse, and cognitive impairment, was not adequately supervised, resulting in an elopement event. The resident had previously expressed a desire to leave the facility and made explicit threats to jump out of a window if not allowed to leave. Staff responded by placing the resident on one-on-one supervision and sending him to the hospital for evaluation of suicidal ideation. Upon return from the hospital, documentation indicated the resident did not have suicidal ideation but continued to express a strong desire to leave the facility. Despite the resident's ongoing exit-seeking behaviors and recent threats, one-on-one supervision was discontinued after a period of observed calmness. The care plan did not include specific interventions related to placement on a secured unit for increased elopement risk, and there was a lack of clear communication among staff regarding the resident's supervision status. On the morning following the removal of one-on-one supervision, the resident was able to remove a windowpane from his room and exit the building undetected by staff, ultimately falling two stories to the pavement below and sustaining serious injuries. Interviews and record reviews revealed that staff were aware of the resident's history and behaviors, including his repeated requests to leave, agitation, and threats of self-harm. However, the facility failed to maintain adequate supervision and did not implement or communicate effective interventions to prevent the resident's elopement, despite clear indications of risk. The incident resulted in significant physical harm to the resident and was determined to be a result of insufficient supervision and failure to address known hazards.
Failure to Notify Residents of Menu Changes
Penalty
Summary
The facility failed to notify residents of a change to the lunch menu in a timely manner, as required by facility policy. On the specified date, the posted menu indicated that beef pot roast, brown gravy, mashed potatoes, glazed carrots, and pineapple tidbits would be served for lunch. However, during meal preparation, dietary staff substituted hamburgers on wheat bread for the pot roast because the pot roast was not ready. The Dietary Manager confirmed that residents were not informed of this substitution, either verbally or by posted notice, despite the facility's policy requiring notification of menu changes at the earliest convenience. This deficiency affected all residents who accepted food from the kitchen, with the exception of two residents who did not receive food from the kitchen.
Failure to Maintain Room Temperature Controls and Sanitary Shower Facilities
Penalty
Summary
The facility failed to ensure residents had control over their room temperature and did not maintain sanitary shower rooms. One resident, who had multiple diagnoses including congestive heart failure, bipolar disorder, anxiety disorder, noncompliance with medical treatment, and cellulitis, was unable to adjust the air conditioning in their room due to a missing temperature control knob. The resident reported being cold throughout the night and not knowing how to operate the unit, as no instructions were provided. The Maintenance Director confirmed the absence of the knob on the air conditioner control. Additionally, observations revealed unsanitary conditions in multiple shower rooms. The women's locked unit shower room had significant water damage causing the sheet rock to pull away from the wall and a mildewed shower curtain. The 100-unit shower room had a non-flushing toilet filled with brown water, which had not been reported to maintenance for at least a week. The 300-unit shower room had pieces of stool on the floor near the drain. Staff interviews confirmed these issues, and the Maintenance Director and Administrator acknowledged the unsanitary conditions and lack of timely repairs.
Failure to Timely Notify Physician of Significant Injury After Resident Fall
Penalty
Summary
The facility failed to ensure timely physician notification of diagnostic results for a resident who experienced an unwitnessed fall resulting in a shoulder fracture. The resident, who had multiple diagnoses including chronic obstructive pulmonary disease, type II diabetes, schizoaffective disorder, and a history of repeated falls, was found to have a fracture dislocation of the left shoulder on X-ray. The care plan required immediate provider notification for falls with significant injury. However, after the X-ray results were received, the LPN did not notify the physician directly but instead gave the results to the DON, as per protocol at the time. The Medical Director later stated he was not informed of the X-ray findings until two days after the results were available and indicated that, had he been notified, he would have sent the resident to the hospital for evaluation and treatment. The facility's policy required immediate practitioner notification by phone when a fall resulted in significant injury. The failure to notify the physician promptly led to a delay in appropriate medical evaluation and intervention for the resident's injury.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report allegations of abuse to the State Agency in a timely manner, as required by policy. Two residents were involved in an incident where one resident, who had a history of wandering and behavioral issues, was struck and scratched by another resident with a history of aggression and multiple psychiatric diagnoses. The incident occurred when a staff member witnessed one resident hitting another in the face and scratching her arms and face while attempting to remove her from another resident's room. The affected resident sustained three superficial scratches on the right side of her face. The incident was documented, and appropriate notifications within the facility were made, but the event was not reported to the State Agency. During interviews, the Administrator confirmed that the incident was investigated internally and determined not to be abuse, and therefore was not reported to the State Agency. The facility's policy required reporting abuse allegations to the state survey agency within 24 hours if the event did not involve abuse or result in serious bodily injury. Despite this, the incident was not reported, resulting in noncompliance with regulatory requirements.
Failure to Complete PASRR Screening Prior to Admission
Penalty
Summary
The facility failed to ensure that a resident received the required Pre-Admission Screening and Resident Review (PASRR) prior to admission. Record review showed that the resident, who had diagnoses including paraplegia, opioid dependence, chronic post-traumatic stress disorder, schizoaffective disorder bipolar type, dependent personality disorder, and generalized anxiety disorder, was admitted without documentation of a PASRR screening in the medical record. The most recent MDS assessment indicated the resident was cognitively intact, had no behaviors, did not reject care, and did not wander. During an interview, the social worker confirmed that residents coming from the hospital should have been screened for PASRR before admission and verified that there was no evidence of PASRR screening for this resident. Facility policy required screening for major mental disability before admission, with Level II PASRR screens sent to Behavioral Consulting Services prior to admission.
Failure to Reassess for PASRR After New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident was reassessed for the Pre-Admission Screening and Resident Review (PASRR) following significant changes in mental health diagnoses and the initiation of new psychotropic medications. Specifically, the resident was admitted with multiple diagnoses, including hemiplegia, type II diabetes, unspecified anxiety disorder, unspecified persistent mood disorder, and chronic systolic heart failure. The medical record showed that the resident received new diagnoses of unspecified anxiety disorder and persistent mood (affective) disorder, and was prescribed several psychotropic medications, including Divalproex sodium, Ativan, and Lexapro, on multiple occasions. Despite these significant changes, there was no evidence in the medical record that a significant change PASRR assessment was completed after the new diagnoses or after the psychotropic medications were ordered. During an interview, the social worker confirmed that she had not reassessed the resident for PASRR because she was unaware of the changes in diagnoses and medications. Facility policy required the social worker to coordinate PASRR assessments and notify appropriate services if Level II services were needed, but this process was not followed in this case.
Failure to Hold Interdisciplinary Quarterly Care Conferences
Penalty
Summary
The facility failed to ensure that residents received quarterly care conferences attended by members of the interdisciplinary team (IDT), as required. For three residents reviewed, care conferences were either not held quarterly or, when held, did not include participation from the full IDT. In one case, a resident with multiple diagnoses including hemiplegia, diabetes, and heart failure had only a single care conference documented with the social worker present and no other IDT members. In another instance, a resident with cognitive intactness and multiple psychiatric and neurological diagnoses had not had a documented care conference since the previous year, and while the social worker communicated with the resident's guardian, these interactions were not documented as care conferences nor did they include the IDT. For a third resident with chronic illnesses and moderate cognitive impairment, the last care conference was conducted by phone between the social worker and the legal representative, without the resident or other IDT members present. Interviews with the social worker confirmed that quarterly care conferences were not consistently held and that the IDT was not routinely involved. The social worker cited reasons such as the resident's cognitive status, lack of response from other team members, and challenges in reaching legal representatives. Facility policy indicated that residents and their representatives should be encouraged to participate in the care planning process and be given advance notice of care conferences, but this was not consistently followed for the residents reviewed.
Failure to Timely Treat Displaced Shoulder Joint After Fall
Penalty
Summary
The facility failed to provide timely treatment and care for a resident who sustained a displaced shoulder joint following a fall. The resident, who had multiple diagnoses including repeated falls, impaired cognition, and psychiatric disorders, experienced an unwitnessed fall resulting in a shoulder injury. Although the resident later reported increasing pain in her arm, and an X-ray confirmed a fracture dislocation with abnormal positioning and fracture fragments, there was no immediate action taken to address the injury. The X-ray results were reviewed, but no new orders were given, and the physician was not notified promptly as required by facility policy. The delay in notifying the attending physician and obtaining appropriate medical treatment resulted in the resident continuing to experience pain, swelling, and functional impairment for two days before being sent to the hospital. Interviews revealed that the LPN provided the X-ray results to the DON, who did not notify the medical director. The medical director confirmed he was unaware of the injury until his next visit, at which point he ordered the resident to be sent to the hospital for evaluation and treatment. Facility policy required timely physician notification and immediate medical treatment for injuries after a fall, which was not followed in this case.
Failure to Facilitate Scheduled Mental Health Appointment
Penalty
Summary
The facility failed to ensure that a resident received necessary behavioral health care and services by not facilitating attendance at a scheduled mental health telemedicine appointment. The resident, who was admitted with multiple psychiatric diagnoses including schizoaffective disorder bipolar type, suicidal ideations, substance abuse, antisocial personality disorder, and mild neurocognitive disorder with behavioral disturbance, was cognitively intact at the time of admission. Hospital records indicated that a telemedicine appointment with psychiatry was scheduled for the resident, and the hospital's Licensed Social Worker was to call the resident at the facility for this consult. The deficiency occurred because the clinical team did not review the resident's admission in the morning meeting as usual, due to the Assistant Director of Nursing being assigned to the floor. As a result, the scheduled mental health appointment was not communicated or facilitated, and the ADON was unaware of the appointment. The administrator later confirmed that the appointment was clearly documented in the hospital paperwork provided at admission. Facility policy required timely communication of admission information to appropriate departments, but this did not occur in this instance.
Failure to Administer Medications as Prescribed and Improper Borrowing of Resident Medications
Penalty
Summary
The facility failed to ensure that medications were administered as prescribed for three residents out of eight reviewed for medication administration. Specifically, one resident with multiple diagnoses, including a humerus fracture, diabetes, malnutrition, hypertension, and intracerebral hemorrhage, had a physician order for Carvedilol 25 mg twice daily. Another resident with congestive heart failure, interstitial lung disease, diabetes, psychotic disorder, and dementia had an order for Fenofibrate 145 mg at bedtime. A third resident with diastolic heart failure, bipolar disorder, anxiety, noncompliance with medical treatment, and cellulitis had multiple medication orders, including Depakote ER, Fenofibrate, Valsartan, Colace, Digoxin, Carvedilol, Spironolactone, Eliquis, and Flomax. On a specific date, the Medication Administration Record showed that the third resident was scheduled to receive several medications at 9:00 PM but only received a partial dose of Colace and refused the rest. During an interview, an LPN admitted to borrowing medications from other residents, including Fenofibrate and Carvedilol, to administer to the third resident because the resident's own medications were unavailable. The LPN stated it was easier to obtain medications from other residents than from the emergency drug supply. Facility policy explicitly prohibited administering medications ordered for one resident to another. This practice was confirmed as a deficiency under the cited complaint numbers.
Inaccurate Medical Record Documentation for Multiple Residents
Penalty
Summary
The facility failed to ensure that information documented in the medical records was accurate for three residents. For one resident with paraplegia, a stage III pressure ulcer, and other complex diagnoses, the discharge documentation inaccurately stated that the resident was discharged to another nursing facility, when in fact the resident was observed leaving the facility independently in a wheelchair and was not admitted to another facility. The discharge notice also included allegations that the resident had threatened others, but the actual discharge location was not as documented. Another resident with multiple medical and psychiatric diagnoses, including a recent shoulder fracture from a fall, had an X-ray confirming a fracture dislocation. The LPN documented that the X-ray results were reviewed and that there were no new orders, but during interviews, it was revealed that the physician was not notified of the results as required. The medical director confirmed he was unaware of the X-ray findings until two days later and would have sent the resident to the hospital had he been informed. A third resident with psychiatric and substance use diagnoses had a late entry progress note indicating that the provider was notified about discontinuation of one-to-one supervision. However, the LPN later admitted that this documentation was false and that no provider was actually notified. Facility policy required that documentation in the medical record be objective, complete, and accurate, which was not followed in these cases.
Sanitation Deficiencies in Kitchen and Food Storage Areas
Penalty
Summary
The facility failed to maintain a sanitary kitchen environment, which had the potential to affect 60 of 60 residents who received food from the kitchen. Observations revealed multiple sanitation issues, including a four-foot diameter floor fan with gray fuzzy debris blowing across the kitchen area, exhaust louvers with heavy grease buildup, and ceiling fan louvers with a heavy buildup of gray fuzzy debris. Additionally, there was a three-foot-wide exhaust fan louver with a heavy buildup of a black wet substance, and the ceiling above the stove had splatters of a brown substance. The kitchen also had missing, exposed, broken, and heavily soiled ceiling tiles, and the flooring had a heavy buildup of black debris. Further issues included heavily soiled meal plate warmer equipment, missing caulking in the dishwashing area, and blackened dish table walls consistent with mold. The ice machine had a pink wet substance consistent with mold, and there was no thermometer or temperature log for the food storage freezer chest and milk cooler. Multiple foods were unlabeled, undated, and expired in the resident-designated refrigerators. The Dietary Manager confirmed these issues and acknowledged the need for cleaning and repairs. The facility's policy required the food service area to be maintained in a clean and sanitary manner, which was not adhered to.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to provide a safe, comfortable, and clean environment for its residents, affecting 13 out of 19 residents on the women's secured unit. One resident, who had been residing in a room for several months, was subjected to vulgar handwritten statements on the walls, which were left by a previous occupant. Despite the resident's complaints, the facility did not remove the offensive writing. Another resident's room was excessively hot, reaching 83 degrees Fahrenheit, with no air-cooling equipment provided, causing discomfort and sleep disturbances. The facility did not offer alternative accommodations or monitor the room temperature. Several residents, including those with severely impaired cognition, were found in rooms with temperatures at the upper limit of the acceptable range, without any air-cooling equipment. These residents were not provided with adequate means to cool their rooms, and there was no documentation of temperature monitoring. One resident was only moved to a cooler room after the issue was identified by a maintenance assistant. Additionally, the interior smoke room on the women's secured unit was in disrepair, with insufficient ashtrays, a non-operational air fan, and walls discolored with nicotine. The room was not cleaned or maintained, leading to a buildup of cigarette ashes on the floor and inadequate ventilation. The facility's policy on maintenance and storage areas was not adhered to, as the smoke room was not kept in a clean and safe manner.
Facility Fails to Ensure Visual Privacy for Residents
Penalty
Summary
The facility failed to ensure that resident bedrooms provided visual privacy, affecting eight residents on the secured women's unit. Observations revealed that privacy curtains did not completely encircle the beds for some residents, and one resident had no privacy curtain at all. Interviews with staff and residents confirmed the lack of adequate privacy measures, with residents expressing a desire for privacy from their roommates during care. The facility's policy on privacy, dated September 2019, stated that privacy would be provided in all aspects of care, which was not adhered to in these instances. Additionally, the facility did not provide window blinds in certain resident rooms, further compromising visual privacy. This affected five residents who were observed to have no window blinds, and interviews with staff and residents confirmed the need for window coverings to ensure privacy during care. The deficiency was investigated under Complaint Number OH00155399, highlighting the facility's noncompliance with its own privacy policy.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents on the women's secured unit, affecting 19 residents. Observations revealed that the shower room had a blackened substance resembling mold at the base of the shower stall and adjacent walls. The shower exhaust fan was covered with a gray fuzzy layer and was not operational. Additionally, the shower privacy curtain was torn and not fully attached, compromising privacy. Interviews with staff confirmed these issues, and it was noted that all residents on the women's unit used this main shower room. Further observations identified a missing span of drywall around the faucets in the chemical room, exposing the interior wall. A room labeled as a whirlpool room was being used for storage and was filled with files and paperwork. This room also had a leaking shower head, resulting in mold-like substance on the floor. Staff interviews confirmed the disrepair of the chemical room wall and the leaking shower head. The facility's policy on storage areas and maintenance, dated December 2009, was reviewed and indicated that storage areas should be maintained in a clean and safe manner, and maintenance services should ensure the building is in good repair and free from hazards.
Failure to Provide Vision Services
Penalty
Summary
The facility failed to ensure that a resident received the necessary vision services and assistive devices. Resident #23, who was admitted with diagnoses including chronic obstructive pulmonary disease, schizoaffective disorder, dementia, and generalized anxiety disorder, was recommended eyeglasses by an optometrist on 11/15/23. Despite being cognitively intact as per the Minimum Data Set assessment dated 06/06/24, the resident did not have eyeglasses. An interview with a Licensed Practical Nurse on 08/06/24 confirmed the absence of eyeglasses for the resident. An observation on the same day revealed the resident squinting to read a clock, and the resident confirmed his need for eyeglasses. A Social Worker Designee confirmed that the optometrist was supposed to order the eyeglasses, but this had not been done, resulting in the resident not receiving them.
Failure to Submit PBJ Staffing Data
Penalty
Summary
The facility failed to submit complete and accurate staffing information for the Payroll-Based Journal (PBJ) staffing report to the Centers for Medicare and Medicaid Services (CMS) for the first quarter of 2024. This deficiency was identified through a review of the PBJ staffing data report, which revealed that no data had been submitted for that period. During an interview, the Regional Operations Manager and the Administrator confirmed the omission. The Administrator had submitted the necessary information to the facility's corporate office, expecting them to forward it to CMS. However, the individual responsible for the submission was a contractor whose contract was terminated, and he did not provide the login credentials needed for submission. Consequently, the facility had to create a new profile to ensure future compliance.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 861 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Cincinnati
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Garden Park Health Care Center | 0.2 mi | ★★★★★ | 3 | 0 |
| Lincoln Crawford Care Center | 1.5 mi | ★★★★★ | 7 | 0 |
| Scarlet Oaks Nursing And Rehabilitation Center | 1.5 mi | ★★★★★ | 0 | 0 |
| Norwood Towers Post-acute | 1.6 mi | ★★★★★ | 30 | 0 |
| Seven Acres Senior Living At Clifton | 1.8 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.