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 Atrium Nursing And Rehabilitation during CMS and state inspections, most recent first.
A facility failed to document the reason for resident transfers when it temporarily closed and moved 16 residents to a sister facility. Records for three residents showed no transfer reason in the chart, even though one resident’s daughter/POA and two legal guardians were contacted and agreed to the move. One guardian said the first notice received was an email about renovations and relocation, and the Administrator confirmed phone calls were made but not documented.
Failure to provide required transfer and closure notifications: The facility transferred all residents due to a temporary closure for renovations but did not give 30-day written notice to residents or their reps. The DON, Administrator, and other staff confirmed families were told by phone or email, but there was no documentation of the calls, and one POA said notice was given only when the resident moved out. The facility also delayed notifying the State LTC Ombudsman and did not show receipt of the closure plan by the State Agency.
The facility failed to submit closure plan procedures to the State Agency and did not notify the Ombudsman before relocating residents during a temporary closure for renovation. Surveyors confirmed the facility was empty, 16 residents had been transferred to a sister facility, and the Ombudsman notification occurred after transfers had already begun.
Failure to Report and Investigate Alleged Sexual Abuse: A cognitively intact resident reported that another resident showed her breasts, tried to kiss him, and called him unwanted names. Multiple staff members said they heard about the allegation but did not report it because they believed administration already knew. The DON and Administrator were not aware until the surveyor raised the issue, and the allegation was not entered in the facility’s SRI system as required by policy.
A resident who was cognitively intact reported that another resident showed her breasts or sports bra, tried to kiss him, and called him unwanted names. Multiple staff members said they heard about the allegation about a month earlier, but they did not report it because they believed administration already knew. The Administrator later verified the allegation was not reported to the state survey agency within the required timeframe, despite the facility abuse policy requiring reporting no later than 24 hours.
Failure to Thoroughly Investigate Alleged Sexual Abuse: A cognitively intact resident reported that another resident showed her breasts, tried to kiss him, and used unwanted names, but the allegation was not reported or thoroughly investigated. Multiple staff said they heard about the incident from others and assumed administration already knew, while the DON was unaware until the surveyor raised it. The residents gave conflicting accounts, and the facility’s abuse policy required immediate reporting and investigation of all alleged abuse.
Late MDS Transmission for Three Residents: The facility failed to timely transmit quarterly MDS assessments to CMS for three residents. Each resident had significant diagnoses, including DM, Parkinson's disease, epilepsy, and major depressive disorder, and there was no record that the assessments were transmitted to or accepted by CMS. An MDS nurse confirmed the assessments were not submitted timely.
A resident admitted with schizophrenia, anxiety, and major depressive disorder had a care plan that did not include any focus, goals, or interventions for those psychiatric diagnoses. Although a psych note added schizophrenia and the resident was cognitively intact on the MDS, the care plan remained incomplete, and the MDS nurse confirmed the omissions.
The facility failed to follow its Water Management Plan and Legionella Risk Assessment, which aimed to reduce the risk of Legionella in the water system. Despite having a plan in place, there was no evidence of regular water temperature checks or room inspections since late 2024. The Maintenance Supervisor and Administrator confirmed the facility's non-compliance, potentially affecting all 18 residents. The CDC recommends comprehensive water management programs to prevent Legionella growth, which the facility did not adhere to.
The facility failed to maintain a clean and homelike environment in the secured behavioral unit, affecting all 18 residents. Observations revealed dirt and fur-like material on heat register/vents and soiled floors. An unoccupied resident room was improperly used as a storage space, with supplies and debris scattered throughout. A RN confirmed these conditions, which violated the facility's policy for a safe, clean, and comfortable environment.
The facility failed to maintain a safe, clean, and homelike environment for three residents. One resident's bathroom had chipping paint, another's room had soiled and peeling wallpaper, and a third's room had food debris and sticky substances on the floor. These conditions were confirmed by staff and contradicted the facility's policy for maintaining a sanitary and comfortable environment.
The facility failed to offer care conferences to two residents, both cognitively intact and requiring supervision for ADLs, as per the facility's policy. Despite being admitted with various diagnoses, neither resident nor their guardians were documented as having been offered or received care conferences. Interviews confirmed the lack of opportunity for participation in care planning.
The facility failed to obtain signed refusal forms for vaccinations and did not gather prior immunization information for two residents. One resident refused several vaccines without signing refusal forms, while another newly admitted resident had no immunization records documented. The facility's policy required assessment of vaccinations upon admission, which was not followed.
The facility failed to convey funds within 30 days for three residents after discharge. One resident's funds were delayed due to a check processing issue, another's funds were delayed by several months, and a third resident's funds were not conveyed at all due to a lack of authorization. These deficiencies were confirmed by the facility's administrator.
A facility failed to ensure a resident's advanced directives were consistent across records. The resident, with multiple diagnoses, was ordered as DNR-CC, but a paper chart incorrectly indicated full code status. The DON confirmed the inconsistency and was unaware of any directive changes.
The facility failed to provide activities that met the needs of all residents, affecting three specific residents and the entire resident population. Scheduled group activities were not conducted, and individual preferences were not adequately addressed. Residents expressed dissatisfaction with the lack of engagement in preferred activities, and staff interviews revealed issues with staffing, scheduling, and understanding of residents' preferences.
The facility failed to maintain kitchen sanitation, affecting 39 residents. Observations revealed unlabeled containers, expired milk, and a gray substance on vents and lights. A string hung from a sprinkler head over food prep. Staff confirmed these issues, violating the facility's sanitation policy.
The facility failed to conduct a risk assessment for waterborne pathogens and did not implement a water management program. Additionally, an RN did not follow hand hygiene protocols during medication administration for two residents, as confirmed by interviews and observations. The facility's policies require hand hygiene before and after handling medications and interacting with residents.
The facility failed to maintain accurate PASARR documentation for two residents, as their current mental health diagnoses were not updated in the records. One resident's PASARR document omitted diagnoses such as unspecified psychosis and dementia, while another resident's document did not reflect schizoaffective disorder and bipolar disorder. Staff confirmed the documents were not up to date.
The facility failed to communicate significant mental health changes for two residents to the state mental health agency. One resident had diagnoses such as psychosis and dementia that were not updated in the PASARR document, while another resident's PASARR document was outdated and did not include recent diagnoses like schizoaffective disorder. The MDS nurse and coordinator confirmed the lack of updates and communication.
A resident with a complex medical history, including peripheral vascular disease and substance abuse, experienced inadequate pain management at the facility. Despite a care plan for pain management, the resident had no active pain medication orders and had not been assessed for pain since August. The resident reported significant pain, but staff interviews confirmed the lack of pain assessment and management, with concerns about drug-seeking behavior cited as a reason for not prescribing narcotics.
A facility failed to identify PTSD triggers and develop a trauma-informed care plan for a resident with PTSD, despite documentation of the diagnosis in psychiatric notes. Interviews with staff confirmed the absence of a care plan and a lack of screening tools for trauma history, contrary to the facility's policy.
A resident with severe cognitive impairment and multiple health conditions was administered Metoprolol Tartrate despite specific parameters to hold the medication if vital signs were outside certain limits. The medication was given on several occasions when the resident's vital signs did not meet the prescribed criteria, as confirmed by the DON.
A resident with COPD and other health conditions had medications improperly stored at their bedside, including Anoro Ellipta, Flonase, Albuterol, and Calcium Carbonate, without proper orders or self-administration assessment. Facility staff confirmed the oversight, which violated the facility's medication storage policy.
The facility did not schedule a Registered Nurse (RN) for at least eight consecutive hours on multiple occasions, as confirmed by the Director of Nursing (DON). This failure had the potential to impact all 41 residents in the facility.
The facility's kitchen was found to be unsanitary, with issues such as flies, leaks, and improper hair net use. Observations included a fly swatter near the oven, flies around the steam table, a persistent leak under the sink, and a grease trap overflow. Dead bugs and a grey fuzzy substance were noted in various areas, and dietary aids were not wearing hair nets properly. Despite work orders, no records were found for cleaning the sprinkler heads.
The facility did not inform the Medical Director of high mold levels found in several areas, including a shower room and dining room, potentially affecting all residents. Despite the need for mold remediation, there was no evidence in QAPI documents that the MD was informed, as confirmed by interviews with the MD and Administrator.
The facility failed to maintain essential equipment, including a leaking ice machine, a malfunctioning kitchen stove and oven, and a leaking three-compartment sink. These issues were observed and verified by staff, with reports of long-standing problems that had not been addressed, despite being reported to management.
The facility failed to remediate mold, compromising safety and cleanliness for 41 residents. An inspection revealed high mold levels, requiring specific EPA-registered chemicals and HVAC treatment, which were not implemented. Observations showed mold in multiple areas, water leaks, and damaged flooring. Staff confirmed inadequate cleaning methods, and the administrator admitted remediation was incomplete.
A resident with impaired cognition and at risk for elopement left a secured behavioral unit unsupervised through an unsecured window. The resident, diagnosed with schizophrenia and schizoaffective disorder, was found 2.6 miles away. The facility lacked a specific supervision policy, and the resident was not observed for several hours, allowing the elopement to occur.
The facility failed to provide a clean and safe environment for its residents, affecting 12 residents. Observations revealed missing floor tiles, standing water, strong urine odors, black substances on walls and floors, peeling paint, broken equipment, and cluttered rooms. Staff interviews confirmed these issues, and the facility's policy on Resident Rights was found to be undated.
Failure to Document Transfer Reasons and Prepare Residents for Facility Closure
Penalty
Summary
The facility failed to document the reason for a facility-initiated transfer in the medical record when it temporarily ceased operations and transferred residents to another facility. This affected all 16 residents who were moved out of the building. Review of the records for three residents showed no documentation in their progress notes explaining why the transfers occurred, even though discharge paperwork identified transfer to a sister facility. Resident #17 had diagnoses including major depressive disorder, dementia, and generalized anxiety disorder, and an MDS assessment showed moderately impaired cognition. The record showed the Executive Director spoke with the resident’s daughter/POA on the day of transfer, and the daughter agreed to the move, but the chart did not document the reason for the transfer. The daughter stated she received the discharge notice the same day the resident was moved. Resident #18 had diagnoses including senile degeneration of the brain, anxiety disorder, cognitive communication deficit, and dysthymic disorder, with severely impaired cognition and a legal guardian. The record showed the Executive Director spoke with the guardian on the day of transfer, and the guardian agreed to the move, but the reason for transfer was not documented. Resident #15 had diagnoses including psychosis, generalized anxiety disorder, dementia, and schizoaffective disorder, with moderately impaired cognition and a legal guardian. The record showed the Executive Director left a voicemail for the guardian about referrals for transfer, and the guardian later stated the first notice he received was an email saying residents would need to be relocated because of renovations. The Administrator and SSD confirmed the decision to close the building for renovations and that phone calls were made, but there was no documentation of those calls or of the transfer reason in the resident records.
Failure to Provide Required Transfer and Closure Notifications
Penalty
Summary
The facility failed to provide written notification to residents and their representatives before transferring residents to another facility due to a temporary closure, failed to notify the State Long-Term Care Ombudsman before the transfers, and failed to notify the State Survey Agency of the plan for the transfers and adequate relocation of the residents. This affected all 16 residents who were transferred from the facility during the temporary closure process. The facility census was zero at the time of observation, and the first resident transfer occurred on 03/20/26, with the last two transfers occurring on 05/08/26. Interviews and record review showed that the Administrator said the decision to close the building for renovations was made in early March 2026 and that families and guardians were notified by phone calls, but there was no documentation of those calls. The Administrator confirmed that 30-day written notices were not provided and stated she was unaware they were required. A resident's POA said the discharge notice was received on the day the resident was moved out, while another resident's guardian said the first notice received was an email stating residents would need to be transferred. The facility's policy required 30-day written notice, in-person meetings, individualized written notice, discharge/transfer planning assistance, and notification to the Ohio Department of Health and the State Long Term Care Ombudsman, but the Ombudsman was not notified until 04/23/26 and no receipt of the closure plan was found in the documents submitted to the State Agency.
Failure to Complete Closure Notification Requirements
Penalty
Summary
The facility failed to submit the required closure plan procedures to the State Agency for the temporary closure of the facility and failed to notify the Ombudsman's office before relocating residents. Observation and interview on 05/27/26 at 7:53 A.M. confirmed there were no residents in the facility, and review of the discharge log showed the first resident was transferred on 03/20/26, with a total of 16 residents transferred and the last two transfers occurring on 05/08/26. Review of documents submitted to the State Agency showed no receipt of the facility's closure plan procedures. The facility's Ombudsman notification showed the Ombudsman was notified on 04/23/26. Interviews with the SSD #2 and DON confirmed residents were transferred to the sister facility due to renovation plans, and the facility policy stated notification has been or will be submitted to the Ohio Department of Health and the State Long Term Care Ombudsman.
Failure to Report and Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to implement its abuse policy after an allegation of sexual abuse involving one resident and another resident. Resident #06 was cognitively intact on the quarterly MDS and reported that Resident #12 showed him her breasts, tried to kiss his hand and cheek, and called him unwanted names such as "baby boo" and "honey." Resident #06 stated he was uncomfortable with the behavior and told staff, but the behavior continued. The facility census was 18, and the report identified this as affecting one of two residents reviewed for abuse. The allegation was not reported in the facility’s self-reported incidents, and the Administrator and DON were not aware of the allegation until the surveyor notified them. Staff interviews showed that CNA #35, RN #600, CNA #24, and RN #27 had heard about Resident #12 allegedly exposing herself or making inappropriate advances, but they did not report it because they believed administration was already aware. The Administrator’s written statement reflected that Resident #06 initially described seeing only a sports bra, while later accounts referenced breasts being exposed. AA #55 and AA #56 also documented that Resident #06 first described the incident as seeing a sports bra, with his account later changing to full exposure after speaking with the DON. Resident #12 denied exposing herself or attempting to kiss Resident #06 and stated she called residents and staff "boo" because she could not remember names due to her medical condition. Review of the facility policy stated that all alleged abuse must be investigated and reported immediately to the Administrator or designee, and the state agency must be notified as soon as possible but no later than 24 hours. The report showed the facility did not report the allegation of sexual abuse or document it in the SRIs as required.
Failure to Timely Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse to the state survey agency in a timely manner. Resident #06 was cognitively intact on the quarterly MDS and reported that another resident showed him her breasts, tried to kiss his hand and cheek, and called him unwanted names such as "baby boo" and "honey." He stated he was uncomfortable with the behavior and told facility staff, but the conduct continued. The facility’s SRI review showed no report of the allegation of sexual abuse or the related behaviors during the review period. Interviews with staff showed multiple employees had heard about the allegation about a month earlier, including that the other resident lifted her shirt or showed her sports bra and made advances toward Resident #06. CNA #35, RN #600, CNA #24, RN #27, and AA #56 each stated they knew about the incident from the resident or from other staff, but did not report it because they believed administration was already aware. The Administrator stated she was not aware of the allegation until the surveyor brought it to her attention and verified the facility did not report the allegation to the state survey agency in a timely manner. The Administrator’s and DON’s witness statements reflected that the resident’s account changed over time from seeing a sports bra to seeing breasts, while the other resident denied exposing herself or attempting to kiss him. The facility’s abuse policy required staff to report allegations immediately to the Administrator or designee, and required the Administrator or designee to notify the state agency of all alleged abuse as soon as possible but no later than 24 hours. The failure involved one resident out of two reviewed for abuse in a facility census of 18.
Failure to Thoroughly Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual abuse involving one resident who was cognitively intact and another resident with dementia, depression, anxiety, diabetes, hypertension, peripheral vascular disease, obesity, and an above-the-knee right leg amputation. Review of the facility’s self-reported incidents showed no report of the allegation that the second resident showed the first resident her breasts, attempted to kiss him, or called him unwanted names. The Administrator later confirmed that no thorough investigation had been completed, and the DON stated she was not aware of the allegation before the surveyor notified the Administrator. Resident interviews and staff statements showed that the first resident reported the second resident showed him her breasts, tried to kiss his hand and cheek, and called him “baby boo” and “honey,” and that he was uncomfortable with the behavior. The resident stated he told staff, but the behavior continued. CNA, RN, and activities staff reported hearing about the incident from other staff or from the resident about a month earlier, but they did not report it because they believed administration was already aware. Staff also stated they had been trying to keep the two residents separated. The Administrator’s written statement reflected that she spoke with both residents after learning of the allegation; the first resident’s account varied between seeing only a sports bra and later stating full exposure, while the second resident denied exposing herself or making sexual advances and said she called residents and staff “boo” because she could not remember names. The DON’s written statement showed she interviewed multiple staff members, all of whom said they had not personally witnessed the event and had only heard about it in report or from the resident. The facility policy required all alleged abuse to be investigated and reported immediately, but the allegation was not thoroughly investigated or reported as required.
Late MDS Transmission for Three Residents
Penalty
Summary
The facility failed to ensure Minimum Data Set (MDS) assessments were transmitted to CMS within 7 days of assessment for three residents. Resident #03, admitted 10/22/21 with diagnoses including type 1 diabetes mellitus, morbid obesity, and major depressive disorder, had a quarterly MDS completed on 10/03/25 with no record that it was transmitted to or accepted by CMS; the last quarterly MDS had been completed and accepted on 07/03/25. Resident #08, admitted 12/16/24 with diagnoses including type 1 diabetes mellitus, pseudobulbar effect, and Parkinson's disease, had a quarterly MDS completed on 09/19/25 with no record of transmission to or acceptance by CMS; the last quarterly MDS had been completed and accepted on 06/20/25. Resident #10, admitted 11/09/22 with diagnoses including epilepsy, alcohol abuse, and Todd's paralysis, had a quarterly MDS completed on 10/03/25 with no record that it was transmitted to or accepted by CMS; the last quarterly MDS had been completed and accepted on 07/03/25. MDS Nurse #26 confirmed on 12/09/25 that the MDS assessments for Residents #03, #08, and #10 were not submitted to CMS timely.
Care Plan Not Updated for Psychiatric Diagnoses
Penalty
Summary
The facility failed to ensure Resident #09’s comprehensive care plan was updated after changes in the resident’s psychiatric diagnoses. Resident #09 was admitted on 09/29/25 with diagnoses including schizophrenia, anxiety disorder, major depressive disorder, and obsessional thoughts and acts. The admission MDS assessment showed the resident was cognitively intact. A psychiatric physician note dated 11/17/25 added a new diagnosis of schizophrenia, and the diagnoses of major depression and anxiety were listed upon admission. However, the comprehensive care plan dated 12/02/25 contained no focus, goals, or interventions for schizophrenia, anxiety, or major depressive disorder. The MDS Nurse confirmed on 12/09/25 that these diagnoses were not included on the care plan. The facility policy stated that care plans are revised as resident information and conditions change and are updated when there is a significant change in condition and at least quarterly with the required MDS assessment.
Failure to Implement Legionella Water Management Plan
Penalty
Summary
The facility failed to adhere to its Water Management Plan and Legionella Risk Assessment, which was designed to reduce the risk of Legionella and other pathogens in the water system. The plan, dated November 2021, outlined specific procedures for maintaining a healthy environment, including regular monitoring of water temperatures and flushing of water systems in unoccupied rooms. However, there was no documented evidence that these procedures were being followed, as water temperature checks and room inspections had not been conducted since December 2024 and November 2024, respectively. The facility's Legionella Environmental Assessment identified several areas of concern, such as hot and cold-water storage tanks, pipes, valves, and medical devices like CPAP machines. Despite this, the facility did not implement the necessary control measures and monitoring as outlined in their plan. The Maintenance Supervisor, who had only been employed for three weeks, confirmed that he was unfamiliar with the Legionella policies and procedures and that the facility was not following the established plan. The Administrator also verified the facility's non-compliance with the Legionella Risk Assessment and Water Management Plan. The Centers for Disease Control and Prevention (CDC) recommends that healthcare facilities develop comprehensive water management programs to mitigate the risk of Legionella growth and transmission. The facility's failure to follow its own Water Management Plan and Legionella Risk Assessment potentially affected all 18 residents, as the facility census was 18 at the time of the survey. The lack of adherence to the plan was confirmed through interviews and a review of facility documents, which showed a significant lapse in the required monitoring and documentation activities.
Failure to Maintain Clean and Homelike Environment in Secured Behavioral Unit
Penalty
Summary
The facility failed to maintain a clean and homelike environment on the secured behavioral unit, which had the potential to affect all 18 residents residing there. Observations on two separate occasions revealed significant cleanliness issues, including fur-like material and dirt hanging from large heat register/vents affixed to the walls, and soiled floors throughout the unit. These conditions were verified by a Registered Nurse (RN) during the observations. Additionally, an unlocked, unoccupied resident room was found to be used improperly as a storage space, containing multiple stacks of supplies, numerous boxes stacked to the ceiling, trash bags of unopened incontinence briefs, trash, and various debris scattered on the floor. Large metal rails were also leaned against the walls. The RN confirmed that the room was being used as a storage room and acknowledged that it should be secured, especially since it was located on a behavioral unit. The facility's policy, which was reviewed, confirmed that residents have the right to a safe, clean, comfortable, and homelike environment, and that housekeeping and maintenance services are necessary to maintain such an environment.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for three residents, as observed during a survey. Resident #25's bathroom had a significant area where the paint was chipping off the tile next to the sink, a condition that had persisted since the resident's admission. This was confirmed by both the resident and the Director of Nursing during separate observations. Resident #30's room was found to have wallpaper that was soiled and peeling, and the cove base was chipped and peeling away from the wall. These conditions were verified by a Registered Nurse during the observation. Resident #29's room had food debris scattered on the floor, black scuff marks, and a yellow sticky substance near the door. The resident was unsure when the floor was last cleaned, and a Licensed Practical Nurse confirmed the room's condition, noting the absence of housekeeping services that day. The facility's policy mandates a safe, clean, comfortable, and homelike environment, which includes maintaining a sanitary and orderly space, but these standards were not met for the residents involved.
Failure to Offer Care Conferences to Residents
Penalty
Summary
The facility failed to ensure that residents and their representatives were offered and received care conferences or the opportunity to participate in care planning. This deficiency affected two residents who were reviewed for participation in care planning and care conferences. Resident #18, who was admitted to the facility with diagnoses including psychotic disorder, major depressive disorder, and schizoaffective disorder, was cognitively intact and required supervision for ADLs. However, there was no documentation from August 22, 2024, to February 4, 2025, indicating that Resident #18 or her guardian were offered or received a care conference. An interview with Resident #18 confirmed that she had not been offered a care conference or the opportunity to participate in her care planning. Similarly, Resident #19, admitted with diagnoses such as Bechet's disease, cerebral infarction, and paranoid schizophrenia, was also cognitively intact and required supervision for ADLs. From December 16, 2024, to February 4, 2025, there was no documentation that Resident #19 or her guardian were offered or received a care conference. An interview with Resident #19 revealed that he had not been offered a care conference or the opportunity to participate in care planning. The facility's policy, dated December 2016, states that residents and their representatives should be encouraged to participate in care planning, with the Social Services Director responsible for notifying them and maintaining records of such notices. However, the facility failed to adhere to this policy, as confirmed by interviews with the Administrator.
Failure to Obtain Vaccination Refusal Signatures and Prior Immunization Information
Penalty
Summary
The facility failed to obtain signed refusal forms for vaccinations and did not gather information related to prior immunizations for newly admitted residents, affecting two residents. Resident #08, who had diagnoses including schizoaffective disorder, schizophrenia, and diabetes mellitus, was documented as refusing the influenza, RSV, and pneumococcal vaccines. However, the facility did not obtain the resident's signature for these refusals. This was confirmed by RN #127, who acknowledged the oversight and stated that it was necessary to obtain a refusal consent signed by the resident or their authorized representative. Resident #13, with diagnoses such as diabetes mellitus, heart failure, and dementia, was newly admitted, and their immunization and vaccination records were blank in the electronic medical record. RN #127 confirmed that the facility failed to obtain any information related to Resident #13's prior immunizations and vaccinations. The facility policy required that all new admissions be assessed for current vaccinations upon admission, but this was not adhered to in the case of Resident #13.
Failure to Convey Resident Funds Timely
Penalty
Summary
The facility failed to convey resident funds within 30 days of discharge, affecting three residents. Resident #87 was discharged on 08/30/24, but their funds were not conveyed until 10/04/24, and a second check was issued on 12/05/24 due to the first check not being processed. Resident #88 was discharged on 04/04/24, but their funds were not conveyed until 10/04/24. Both residents were cognitively intact at the time of discharge, and the delays in conveying funds were confirmed by the facility's administrator. Resident #89, who had impaired cognition, was discharged on 11/30/24, and the facility did not convey their funds or have a signed authorization to manage their funds. The administrator confirmed the lack of documentation and conveyance of funds for Resident #89. These deficiencies were investigated under Complaint Number OH00161817, highlighting the facility's non-compliance with regulations regarding the timely conveyance of resident funds.
Discrepancy in Resident's Advanced Directives
Penalty
Summary
The facility failed to ensure that a resident's advanced directives were updated and accurate in the medical record. This deficiency affected a resident who was admitted with multiple diagnoses, including schizoaffective disorder, hemiplegia, bipolar disorder, and others. The resident was ordered to be Do Not Resuscitate Comfort Care (DNR-CC) as per a physician's order and a signed DNR-CC paper form. However, a plain white paper in the resident's paper chart at the nurse's desk incorrectly indicated that the resident was a full code. An interview with the Director of Nursing (DON) confirmed the discrepancy between the paper chart and the electronic medical record (EMR), and the DON was unaware of any change in the resident's advanced directives.
Failure to Meet Residents' Activity Needs
Penalty
Summary
The facility failed to ensure that activities met the needs of all residents, affecting three specific residents and the entire resident population of 40. Observations on multiple dates revealed that scheduled group activities were not conducted, and interviews with staff confirmed that activities were either not offered or inadequately substituted. The activity calendar listed specific activities, but these were not executed as planned, and there was no documentation of deviations from the schedule. Resident #17, who is cognitively intact and enjoys games and computer activities, participated minimally in activities from May to September 2024. The resident expressed interest in Tic-Tac-Toe and computer games, but these were rarely offered, and participation was not consistently documented. Similarly, Resident #22, who values having choices and enjoys outdoor activities, reported boredom and a lack of engagement in preferred activities. The resident's participation in outdoor and news-related activities was minimal, and staff interviews revealed a lack of awareness of the resident's preferences. Resident #13, with no cognitive impairment, reported that the facility did not engage him in activities, and he primarily stayed in bed. His activity logs showed limited participation in activities that matched his interests, such as music and outdoor activities. Interviews with staff highlighted issues with staffing and scheduling, as well as a lack of communication and understanding of residents' preferences. The facility's activity program was not effectively meeting the comprehensive assessment and preferences of each resident, as required by policy.
Kitchen Sanitation Deficiency
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, which had the potential to affect 39 of 39 residents who receive food from the kitchen. During an observation, surveyors found several issues, including unlabeled and undated containers of cooking oil and brown sugar, an opened and undated fifty-pound bag of white sugar, and expired chocolate milks stored with unexpired ones in the reach-in cooler. Additionally, a thick fuzzy gray substance was observed on the vent behind the ice machine, and the hood lights above the stove also had a gray fuzzy substance. Further observations revealed a string hanging from a sprinkler head above the food preparation area, directly over where macaroni salad was being prepared. Interviews with the dietary aide, district manager, and dietary manager confirmed these findings. The facility's sanitation policy, which was reviewed, stated that all kitchen and dining areas should be kept clean, with equipment disassembled as necessary to prevent grime accumulation. This deficiency was noted as a continuation of non-compliance from a previous complaint survey.
Inadequate Water Management and Hand Hygiene Practices
Penalty
Summary
The facility failed to conduct a risk assessment to identify potential areas of concern related to waterborne pathogen growth, specifically Legionella, and did not implement a water management program. During an interview, the Administrator confirmed the absence of a risk assessment and a water management program, despite the facility's policy from November 2021 stating the need for such a plan to reduce the risk of Legionella and other pathogens in the water system. Additionally, the facility did not adhere to proper hand hygiene protocols during medication administration. Observations revealed that a registered nurse (RN) failed to perform hand hygiene before and after preparing and administering medications to two residents. The RN handled medication cards, bottles, and other items without washing hands, even after touching potentially contaminated surfaces and interacting with residents. This was confirmed during interviews with the RN and the Assistant Director of Nursing, who acknowledged that hand hygiene should have been conducted as per the facility's policies. The facility's policies on hand washing and medication administration, which require staff to maintain good hand hygiene before and after handling medications and interacting with residents, were not followed. The failure to perform hand hygiene was observed during the preparation and administration of medications, and the RN verified the oversight during an interview. The Assistant Director of Nursing also confirmed the necessity of hand hygiene in these situations, as outlined in the facility's guidelines.
Inaccurate PASARR Documentation for Residents
Penalty
Summary
The facility failed to ensure that the Pre-Admission Screening and Resident Review (PASARR) documents for two residents were accurate and reflective of their current conditions and diagnoses. For one resident, the PASARR document did not include updated diagnoses such as unspecified psychosis, psychotic disorders, and dementia, despite these being present in the resident's medical record and care plan. The resident was receiving medications for depression and schizoaffective disorder, which were not accurately reflected in the PASARR documentation. The MDS Nurse confirmed that the PASARR documents were not updated to include these diagnoses. Similarly, another resident's PASARR document was outdated and did not reflect current mental health diagnoses such as schizoaffective disorder, hallucinations, bipolar disorder, and altered mental status. These diagnoses were present in the resident's medical record but not updated in the PASARR documentation. The MDS Coordinator confirmed that the PASARR documents were not up to date with the resident's current mental health diagnoses, acknowledging that updates are required when new diagnoses are added.
Failure to Communicate Significant Mental Health Changes
Penalty
Summary
The facility failed to ensure that significant mental health changes for residents receiving MD or ID services were communicated to the state mental health agency. This deficiency was identified during a review of PASARR documents for two residents. Resident #25, who was admitted with multiple diagnoses including chronic respiratory failure, anxiety disorder, and psychosis, had significant mental health changes that were not updated in her PASARR document. These changes included the addition of unspecified psychosis and psychotic disorders, as well as dementia, which were not communicated to the state mental health agency. The MDS nurse confirmed that the PASARR documents were not updated to reflect these changes. Similarly, Resident #7, who was admitted with diagnoses such as schizoaffective disorder, hallucinations, and bipolar disorder, also had significant mental health changes that were not communicated to the state mental health agency. Her PASARR document was outdated and did not include recent diagnoses such as schizoaffective disorder and altered mental status. The MDS Coordinator confirmed that the PASARR documents were not updated with the most current mental health diagnoses and that the state mental health agency was not notified of these changes.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to adequately assess and manage pain for a resident with a complex medical history, including bipolar disorder, anxiety disorder, substance abuse, and peripheral vascular disease, among others. The resident was admitted with a care plan that included interventions for pain management, such as administering medication as ordered and assessing pain levels using a scale of 1-10. However, the resident's medical record showed no active orders for pain relievers, and the resident had not been monitored for pain since August 21, 2024. Despite the resident's complaints of significant pain, classified as an 8 on a scale of 1-10, there were no active orders for Tylenol or other pain medications, and staff interviews confirmed the lack of pain assessment and management. The resident had previously been treated with Tylenol, Norco, and Toradol at an emergency department visit, but upon return to the facility, there were no active orders for these medications. The facility's Director of Nursing confirmed that the resident had not been on Tylenol since being discharged from a psychiatric hospital in July 2024, and there was no evidence of pain assessment since August 20, 2024. Interviews with the resident and staff revealed that the resident's pain was not being addressed, and the facility's policy on pain management, which required assessment and intervention, was not followed. The failure to manage the resident's pain was attributed to concerns about drug-seeking behavior, but no alternative pain management strategies were implemented.
Failure to Develop Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to identify post-traumatic stress disorder (PTSD) triggers and develop a trauma-informed care plan for a resident diagnosed with PTSD. The resident, admitted with multiple diagnoses including bipolar disorder, PTSD, anxiety disorder, and depression, did not have a trauma-informed care plan despite the presence of PTSD being documented in psychiatric practitioner notes over several months. Interviews with the Assistant Director of Nursing (ADON), a Licensed Practical Nurse (LPN), and the Director of Nursing (DON) confirmed the absence of a care plan addressing trauma-informed care for the resident. The facility also lacked a screening tool or assessment process to identify past trauma history in newly admitted residents. The facility's policy on Trauma Informed Care, revised in March 2019, mandates that nursing staff be trained on screening tools and trauma assessment, and that universal screening for trauma be implemented. However, the policy was not effectively executed, as evidenced by the staff's inability to identify PTSD triggers for the resident and the absence of a trauma-informed care plan.
Failure to Follow Medication Parameters
Penalty
Summary
The facility failed to adhere to medication administration parameters for a resident, leading to the administration of unnecessary drugs. The resident, who had severe cognitive impairment and multiple diagnoses including major depressive disorder, hypertension, myalgia, atrial fibrillation, and dementia, was prescribed Metoprolol Tartrate with specific instructions to hold the medication if systolic blood pressure was less than 110 or heart rate was less than 50. Despite these parameters, the medication was administered on multiple occasions in May, June, and July 2024 when the resident's vital signs were outside the prescribed limits. This was confirmed through a review of the resident's Medication Administration Records and an interview with the Director of Nursing, who acknowledged that the medication should have been withheld under these circumstances.
Improper Medication Storage for a Resident
Penalty
Summary
The facility failed to ensure proper storage of medications for a resident, affecting one of five residents reviewed for medication storage. The resident, who had a medical history including chronic obstructive pulmonary disease (COPD), major depressive disorder, schizoaffective disorder, paroxysmal atrial fibrillation, and a cardiac pacemaker, was found to have several medications left unattended at their bedside. These medications included Anoro Ellipta, Flonase, Albuterol, and Calcium Carbonate, despite the resident not having an active order for Calcium Carbonate and no orders for the Albuterol or Anoro Ellipta to be kept at the bedside for self-administration. Observations and interviews with facility staff, including a registered nurse and the Director of Nursing, confirmed the improper storage of medications and the lack of a self-administration assessment in the resident's medical chart. The facility's policy on medication storage, revised in January 2018, states that only authorized personnel are permitted to access medications, and medications labeled for individual residents should be stored separately from floor stock when not in the medication cart. The failure to adhere to these policies resulted in the deficiency noted in the report.
Failure to Schedule RN for Required Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was scheduled for at least eight consecutive hours daily, which is a requirement for the care of all residents. This deficiency was identified through a review of staffing schedules and confirmed by the Director of Nursing (DON) during an interview. The specific dates on which no RN was scheduled for the required hours were 07/07/24, 07/11/24, 07/15/24, 07/16/24, 07/20/24, 07/21/24, 07/25/24, 07/26/24, 07/29/24, 07/31/24, 08/03/24, and 08/04/24. This oversight had the potential to affect all 41 residents residing in the facility.
Sanitation and Maintenance Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, which had the potential to affect all 41 residents. Observations revealed multiple issues, including a fly swatter placed next to the oven, flies present around the steam table, and a persistent leak below the three-compartment sink that had been reported but not addressed for two years. Additionally, the floor near the grease trap was covered with a thick, dark brown substance, and the grease trap was known to overflow. Dead bugs were found on the floor in the dish room, and a grey fuzzy substance was observed on the wall and ceiling above the reach-in cooler, likely due to condensation. Further observations noted dietary aids improperly wearing hair nets, with hair not fully covered, and a grey fuzzy substance coating the vents of a window air conditioning unit, which was blowing into the food service area. The window below a large fan had streaks of a dried unidentified substance with dead insects stuck to it. A string of grey fuzzy substance was also seen dangling from a sprinkler head above the food preparation counter. Despite work orders being submitted for cleaning, no records were found for the sprinkler heads. The facility's policies required all food service equipment to be in proper working order and all food preparation areas to be maintained in a clean and sanitary manner.
Failure to Inform Medical Director of Mold Findings
Penalty
Summary
The facility failed to inform the Medical Director (MD) of high levels of mold discovered in various areas of the facility, which had the potential to affect all 41 residents. An Environmental and Residential Microbial Inspection Report dated May 13, 2024, revealed that mold testing conducted on May 8, 2024, showed higher levels of mold inside the facility compared to outside. The affected areas included an unoccupied room, the 200 Hall shower room, the 300 hallway, the therapy room, a common area, and the main dining room, all requiring mold remediation. Despite these findings, there was no documented evidence in the Quality Assurance and Performance Improvement (QAPI) meeting documents that the MD was informed of the results. A phone interview with the MD confirmed she was unaware of the mold testing results, and the Administrator also confirmed this oversight.
Failure to Maintain Essential Equipment
Penalty
Summary
The facility failed to maintain essential equipment in a safe and properly functioning manner, which had the potential to affect all residents. Observations revealed multiple issues with equipment, including an ice machine at the entrance to the 200 hall that was leaking water onto the floor, creating a puddle. This was verified by a State tested Nursing Assistant (STNA) and a Licensed Practical Nurse (LPN). Additionally, the kitchen stove was not fully operational, with only one burner functioning properly, and the oven was not in use due to malfunctioning. The District Dietary Manager confirmed these issues, and it was noted that a replacement oven had been ordered but did not fit, and no further action was taken. Further observations in the kitchen revealed a persistent leak below the three-compartment sink, resulting in a puddle of water. This issue had been reported to management multiple times over two years, but no repairs had been made. The grease trap also overflowed when the sink was emptied. Additionally, the top oven of a double oven ran hot, requiring careful monitoring to avoid overcooking food. These deficiencies were documented in the facility's policy, which stated that all food service equipment should be maintained in proper working order.
Mold Remediation Failure in LTC Facility
Penalty
Summary
The facility failed to address and remediate the presence of mold, compromising the safety and cleanliness of the environment for all 41 residents. An inspection conducted by a mold testing company revealed higher levels of mold inside the facility compared to outside, necessitating remediation. The recommended actions included treating HVAC systems with an EPA-registered antimicrobial chemical, replacing air filters, and sanitizing various areas with antimicrobial chemicals followed by air scrubbers. However, these recommendations were not followed, as confirmed by the facility's administrator and maintenance supervisor. Observations within the facility highlighted several issues, including a sticky pad with dead insects, a leaking air conditioning unit causing water accumulation, and damaged wood flooring. Interviews with staff and residents confirmed these conditions, indicating a lack of timely maintenance and repair. Additionally, mold was observed in multiple areas, including under wallpaper, around AC units, and in storage and beauty salon rooms. The maintenance supervisor acknowledged the presence of mold and the inadequate cleaning methods used, such as household bleach, which were not recommended by the mold testing company. The mold testing company confirmed that the facility's mold levels were high and required specific EPA-registered chemicals for proper remediation. The use of household bleach was deemed insufficient, and the facility failed to implement necessary containment and air cleaning measures. The administrator admitted that the mold remediation was not completed as recommended, and the HVAC systems were not properly disinfected. This deficiency was investigated under complaint numbers OH00156510 and OH00155553.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and intervention to prevent a resident with impaired cognition and at risk for elopement from leaving the facility unsupervised. The resident, who resided on a secured behavioral unit, eloped through his bedroom window without staff knowledge and was found 2.6 miles away in a shopping center parking lot. This incident placed the resident at potential risk for serious life-threatening harm and/or injury. The resident involved had a history of psychiatric hospitalization and was diagnosed with conditions including unspecified schizophrenia and schizoaffective disorder bipolar type. Despite being assessed as a low risk for elopement, the resident expressed delusions and had auditory and visual hallucinations. The resident was last seen on the unit the night before the incident and was discovered missing early the next morning when a lab technician attempted to draw blood. Interviews with staff revealed that prior to the incident, all resident windows could be opened completely, allowing for potential elopement. The facility did not have a specific policy for supervision, but staff were expected to observe residents for safety every two to three hours. The resident was not observed by staff between approximately 10:00 P.M. and 4:00 A.M., during which time the elopement occurred.
Removal Plan
- Maintenance staff completed audits of all doors and windows for functionality and security. All resident windows were secured with special hardware to ensure they were not able to be opened greater than six inches.
- The DON assessed all residents for elopement risk and care plans were revised as indicated.
- The Administrator educated all maintenance staff regarding door and window security.
- The DON/designee educated all current staff in person about policies and procedures related to elopement, missing residents, supervision of residents, and abuse/neglect. Assistant Director of Nursing (ADON) #85 and Human Resources (HR) #92 assisted in educating all remaining staff via telephone. The education was completed.
- The Administrator/designee conducted elopement drills with staff scheduled to work on night shift and staff scheduled to work dayshift.
- The facility-initiated audits of all windows to be performed by maintenance personnel. All windows on the B-Unit were audited five times a week for one week, and a minimum of five windows on the A-unit five times a week for one week. All variances will be corrected upon discovery and education/follow-up will be provided as deemed necessary. Further continued ongoing compliance will be further maintained through audits as dictated by the facility quality assurance committee.
- The facility-initiated audits of exit doors to be performed by maintenance personnel three times a week for one week. All variances will be corrected upon discovery and education/follow-up will be provided as deemed necessary. Further continued ongoing compliance will be further maintained through audits as dictated by the facility quality assurance committee.
- The facility held a Quality Assessment and Performance Improvement (QAPI) meeting with the Administrator, DON, Medical Director, and RRN #20 to review the elopement investigation and approve the plan of correction. All protocols were followed and there were no issues noted.
- The facility held a QAPI meeting with the Administrator, DON, Medical Director, ADON #85, ADON #94, and RRN #20. Elopement audits were reviewed, and there were no new issues identified.
Facility Fails to Provide Clean and Safe Environment
Penalty
Summary
The facility failed to provide a clean and safe environment for its residents, affecting 12 residents out of a census of 71. During an initial tour, surveyors observed missing floor tiles, standing water, and soaked bath blankets near the entrance to Unit-A nurses' station. Additionally, several residents' rooms were found to be in poor condition, with strong urine odors, black unknown substances on walls and floors, peeling paint, cobwebs, and broken equipment such as electric beds. Interviews with staff confirmed these observations and the ongoing issues with the facility's environment. Specific rooms were noted to have significant issues. For example, Resident #28 and #69's room had a strong smell of urine, black substances on the walls and floor, peeling paint, and a broken electric bed. Resident #32's room had ripped wallpaper, crumbling plaster, and black fuzzy substances on the walls. The 200-hall resident shower room had a strong odor, blackish color on the floor, and a black fuzzy substance along the walls. Other rooms had similar issues, including broken outlets, holes in walls, and black substances on walls and floors. The Unit-B dining room had a large pile of trash outside the patio doors and large brown stains on the ceiling tiles over the dining tables. The facility's policy on Resident Rights was reviewed and found to be undated, stating that it was the duty of all nursing staff to ensure every resident is accorded all rights. This deficiency represents noncompliance investigated under Complaint Number OH00152368 and is an example of continued noncompliance from previous surveys.
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Illustrative
What surveyors actually found near you
We read the 535 citations issued within 25 miles in the last 12 months — including the 2 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Xenia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alpine Nursing And Rehabilitation Center | 0 mi | ★★★★★ | 0 | 0 |
| Xenia Health And Rehab | 0.2 mi | ★★★★★ | 1 | 0 |
| Overbrook Landing Health And Rehabiliation | 1.5 mi | — | 0 | 0 |
| Trinity Community | 6.7 mi | ★★★★★ | 0 | 0 |
| Friends Extended Care Center | 6.8 mi | ★★★★★ | 10 | 0 |
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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.