Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Austin Trace Health And Rehabilitation during CMS and state inspections, most recent first.
Food storage and sanitation deficiencies were identified when expired coleslaw and cheese were found in a kitchen refrigerator, along with unlabeled and undated cooked beef and lettuce. A dietary staff member confirmed the items were past date or improperly labeled. The dishwasher wash cycle also failed to reach the minimum required temp, with repeated observations showing only 110 degrees F despite a 120 degrees F minimum in the manufacturer’s manual. A large plastic measuring cup was also found stored inside a flour bin.
A resident’s tracheostomy care involved use of a closed suction catheter stored in a non-sterile, unclosed bedside supply bag, despite the procedure being sterile and the manufacturer warning that non-sterile contents could cause infection. During meal service, a CNA used bare hands to butter a resident’s bread. Staff also failed to follow contact precautions for two residents: one CNA entered a room without PPE to deliver a tray, and another room lacked bins for discarding gowns before exiting.
The facility failed to notify the physician of a resident fall. A resident with epilepsy and mild intellectual disability fell while trying to move a wheelchair and table closer to reach them, and the physician was not notified until the next day. An ADON/LPN confirmed the delay and stated physicians should be notified immediately of resident falls and accidents.
Failure to Document Nonpharmacological Interventions Before PRN Ativan: A resident with respiratory failure, DM2, MDD, and CKD received PRN Ativan repeatedly over several months without documentation that nonpharmacological interventions were attempted first. The MAR showed multiple administrations, the MDS noted the resident was cognitively intact and taking antianxiety medication, and an ADON/LPN confirmed the lack of documentation for attempted nonpharmacological measures before the PRN psychotropic was given.
A resident admitted with intracerebral hemorrhage, left-hand contracture, trach status, and PEG status had a care plan that did not address the left-hand contracture or include interventions to prevent worsening or decreased ROM. The MDS showed intact cognition, ADL dependence, and upper-extremity impairment, and a physician order directed use of a left-hand splint with staff checks under the brace on dayshift. The DON confirmed the contracture was not addressed in the care plan.
Care Plan Not Updated After Falls: A resident with epilepsy and mild intellectual disabilities had two falls, and the facility identified several new fall-prevention interventions, including alarms, toilet handrails, non-slip socks, bed wheel locks, restorative nursing, a reacher, and a low bed. However, the care plan was not updated to reflect several of these interventions, and the RDOC confirmed the omission.
Failure to Obtain Wound Order and Document Skin Findings: Staff provided wound care for a resident’s forehead laceration before obtaining a provider order, and staff also failed to accurately document skin findings for two residents. One resident had multiple bruises and two small open areas that were observed but not charted, and another resident had a scabbed toe area that was known to staff but not documented in the medical record.
A resident with multiple serious diagnoses, including spinal infection and psychiatric conditions, had a PRN order for oxycodone for pain. MAR review showed the opioid was administered multiple times even though staff documented the resident’s pain as zero on a 0-to-10 scale before each dose. The RNUM and DON both verified the medication was given despite the zero pain rating, and facility policy stated pain is rated from zero as no pain and medications are to be given in accordance with physician orders and accepted standards of practice.
A facility failed to assess a resident for the use of physical restraints, specifically alarms, despite the resident's history of falls and medical conditions. The facility's policy requires restraint assessments, but none were documented for the alarms used. The Corporate Nurse confirmed the lack of assessments, contradicting the facility's policy on restraint use.
A facility failed to implement fall interventions for a resident with a history of falls, as outlined in their care plan. The resident, with multiple medical conditions and moderate cognitive impairment, required specific interventions like non-skid strips and visual reminders, which were missing from their room. This oversight was confirmed by an STNA, highlighting a failure to adhere to the facility's Fall Management policy.
A resident with ALS and a PEG tube for enteral feedings experienced a deficiency in care when the facility failed to maintain the tube's integrity. The tube had a break, and staff used medical tape to address the issue, which was not in line with proper procedures. Despite the resident's awareness of the problem, staff continued to use the tube improperly, leading to a hospital visit for replacement. Interviews revealed a lack of communication and awareness among staff regarding the tube's condition.
A resident's medications were left unsecured at the bedside for several days, contrary to the facility's policy requiring staff to administer medication and remain with the resident while it is swallowed. The resident, who was cognitively intact and had a PEG tube, confirmed the medications were left without a physician's order. The RN was unaware of the medications' contents or duration at the bedside.
Food Storage, Labeling, and Dishwasher Temperature Deficiencies
Penalty
Summary
The facility failed to store and label food properly in the kitchen refrigerator. During observation, a container of coleslaw was found with a use-by date of 05/30/26, a block of cheese had a use-by date of 06/06/26, and there were two containers of opened lettuce and a container of cooked beef that were both unlabeled and undated. The dietary staff member confirmed that the coleslaw and cheese were past their use-by dates and should have been discarded, and that the beef and lettuce should have been labeled and dated when opened. The facility also failed to ensure the low-temperature dishwasher reached the proper wash-cycle temperature. The dishwasher temperature log for 06/08/26 showed a wash cycle temperature of 120 degrees Fahrenheit, and the dietary staff member confirmed that entry. When the dishwasher was observed running three times, the wash cycle temperature reached only 110 degrees Fahrenheit each time. Review of the manufacturer’s manual for Model 5AGES or WS2 showed an operating temperature minimum of 120 degrees Fahrenheit, with 130 to 140 degrees Fahrenheit recommended. In addition, dry storage observation showed a large plastic measuring cup stored inside the plastic flour bin, which the dietary manager confirmed should not have been stored there.
Infection Control Failures During Tracheostomy Care, Meal Service, and Contact Precautions
Penalty
Summary
Sterile equipment was not ensured during tracheostomy care for one resident with a tracheostomy, gastrostomy status, nontraumatic intracerebral hemorrhage, and left hand contracture. The resident’s record showed intact cognition and supervision needs with ADLs. During observed tracheostomy care, the respiratory therapist removed the tracheostomy dressing, cleansed the area with saline and gauze, and used a closed suction tracheal catheter that had been stored at the bedside in a clear supply bag. The catheter was connected to suction tubing on the bedside table and used to suction the resident’s tracheostomy tube, then returned to the supply bag. The therapist also removed the inner cannula and replaced it using sterile technique. The therapist confirmed the closed system was stored at bedside in a non-sterile, unclosed supply bag and acknowledged the t-piece remained open during storage. The manufacturer’s instructions stated the product was intended for ventilator-dependent patients and warned that non-sterile contents could cause infection. Proper infection control was not followed during meal service for another resident with Alzheimer’s disease, peripheral vascular disease, and chronic kidney disease who required set-up assistance with eating and had moderately impaired cognition. During lunch service, a CNA removed the tray from the cart, placed it in front of the resident, opened the tray lid, and then used bare hands to grab the resident’s bread and butter it. The CNA confirmed she used her bare hands and touched the bread to butter it. Staff also failed to follow transmission-based precautions for two residents on contact precautions. One resident had an order for contact precautions for klebsiella pneumonia, indwelling devices, and wounds; although a contact precaution sign and PPE cart were outside the room, a CNA entered to deliver the lunch tray without donning PPE. Another resident had an order for contact isolation due to VRE, with a contact isolation sign and PPE cart at the room entrance. Observation showed there were no bins or containers inside the room for staff to discard gowns before exiting, and an LPN confirmed there were no bins in the room for that purpose. The facility policy required standard and transmission-based precautions, and CDC guidance stated staff should wear gown and gloves for contact precautions and don PPE upon room entry and properly discard it before exiting.
Delayed Physician Notification After Resident Fall
Penalty
Summary
The facility failed to notify the physician of a resident fall for Resident #89, affecting 1 of 24 residents sampled. Resident #89 was admitted on 12/11/24 with diagnoses including epilepsy and mild intellectual disability, and the MDS dated 03/12/26 indicated the resident was cognitively intact. The fall investigation showed the resident fell on 06/05/26 at 11:05 P.M. while trying to move the wheelchair and table closer to reach them. Review of the progress notes showed the resident's physician was not notified of the fall until 06/06/26 at 5:45 P.M. During interview on 06/10/26 at 2:25 P.M., the ADON/LPN confirmed the physician was not notified immediately after the fall and stated the facility should notify physicians immediately of resident falls and accidents. The facility policy titled Fall Management, dated 01/23/25, included physician notification of falls.
Failure to Document Nonpharmacological Interventions Before PRN Ativan
Penalty
Summary
The facility failed to ensure nonpharmacological interventions were attempted before administering as-needed psychotropic medication to Resident #3. The resident was admitted with diagnoses including acute and chronic respiratory failure with hypoxia, type 2 diabetes mellitus, major depressive disorder, and chronic kidney disease. Physician orders included Ativan 1 mg by mouth every 6 hours as needed for anxiety, first with a stop date and later continued as an ongoing PRN order. Review of the MAR showed Ativan was administered repeatedly from November 2025 through June 2026 without documentation that nonpharmacological interventions had been attempted first, including 7 administrations in November, 17 in December, 9 in January, 22 in February, 22 in March, 14 in April, 5 in May, and 3 in June. The MDS dated 05/15/26 identified the resident as cognitively intact, required assistance with ADLs, and taking antianxiety medication. During interview, the ADON/LPN confirmed there was no documentation of nonpharmacological interventions being attempted prior to administering PRN Ativan on multiple dates since 11/18/25 and stated the facility expectation was for staff to attempt such interventions before giving psychotropic medication.
Incomplete Care Plan for Left-Hand Contracture
Penalty
Summary
The facility failed to develop comprehensive care plans for Resident #30, who was admitted with diagnoses including nontraumatic intracerebral hemorrhage, contracture of the left hand, tracheostomy status, and gastrostomy status. The MDS assessment dated 06/05/25 showed the resident had intact cognition, required staff assistance with ADLs, and had impairment to one side of the upper extremity. A physician order dated 11/14/25 directed the resident to wear a left-hand splint at his own discretion and for staff to check under the brace as the resident would allow every dayshift. Review of the care plan showed it did not include the resident's left-hand contracture or interventions to prevent worsening or decreased ROM. The DON confirmed on 06/11/26 that the resident had a left-hand contracture that was not addressed in the care plan.
Care Plan Not Updated After Resident Falls
Penalty
Summary
The facility failed to keep Resident #89’s care plan updated with new interventions after the resident experienced falls. Resident #89 was admitted on 12/11/24 with diagnoses including epilepsy and mild intellectual disabilities, and the MDS dated 03/12/26 indicated intact cognition and a need for assistance with ADLs. The resident’s fall investigations on 06/05/26 documented two separate falls: one while trying on new pants and another while trying to move a wheelchair and table closer to reach them. Following the falls, the facility identified multiple interventions, including a chair alarm, bed alarm, handrails on the sides of the toilet, non-slip socks, locking the wheels on the bed, restorative nursing, an assistive device (reacher), and a low bed. Review of the care plan showed the resident was at risk for falls, but it was not updated to include several of these newly initiated interventions, including handrails on the sides of the toilet, non-slip socks, locking the wheels on the bed, restorative nursing, an assistive device (reacher), and a low bed. The RDOC confirmed during interview that the care plan had not been updated with the new interventions determined after the resident’s falls.
Failure to Obtain Wound Order and Document Skin Conditions
Penalty
Summary
The facility failed to ensure staff obtained a physician’s order before providing wound treatment for one resident with a left forehead laceration. The resident had diagnoses including epilepsy and mild intellectual disabilities and was noted to have intact cognition and need assistance with ADLs. After the laceration was cleansed, steri-strips were applied and covered with bordered gauze, and staff later signed the treatment administration record for wound care each shift. The physician’s order for the wound was not obtained until the following day, and the ADON confirmed the nurse had not obtained the order and should have done so. The facility also failed to accurately document skin conditions for a resident with diagnoses including atherosclerotic heart disease, bipolar disorder, and CHF who had intact cognition and required supervision with ADLs. The resident’s care plan identified risk for bruising and abnormal lab work related to aspirin use and included monitoring for bruising. However, progress notes, shower sheets, and a non-pressure skin assessment did not document bruises or skin tears, even though observation showed multiple bruises on the upper extremities and two small open areas on the left lower extremity. The resident stated he had bumped into things and bumped his leg, and the RNUM confirmed the bruises and open skin tears had not been documented. The facility also failed to document a scabbed area on another resident’s right second toe. That resident had CHF, DM, Parkinson’s disease, and dementia and was dependent on staff for ADLs. A skin assessment did not include the scabbed area, but observation showed a scabbed area measuring approximately 0.6 cm by 0.6 cm on the middle of the right second toe. The RNUM and WNLPN both confirmed the area was known to staff but was not documented in the medical record, and the WNLPN stated there were no measurements, discovery date, or ongoing monitoring documented.
PRN Oxycodone Given Despite Zero Pain Rating
Penalty
Summary
The facility failed to ensure an adequate indication for administration of pain medication for one resident. Resident #37 was admitted with diagnoses including intraspinal abscess and granuloma, bipolar disorder, schizoaffective disorder, and osteomyelitis of the vertebra. The resident’s MDS assessment indicated intact cognition and a need for staff assistance with ADLs. A physician order dated 04/30/26 authorized oxycodone 5 mg every 4 hours as needed for pain. Review of the MARs for May and June 2026 showed oxycodone was administered multiple times even though the resident’s pain was documented as zero on a 0-to-10 scale before each administration. The medication was given on 05/02/26, 05/03/26, 05/10/26 twice, 05/16/26, 05/23/26, 05/31/26, and 06/06/26 with pain documented as zero. The RNUM verified staff gave oxycodone despite the zero pain rating, and the DON confirmed the resident’s pain level was documented as zero prior to multiple PRN oxycodone administrations. Facility policy stated pain assessment uses a numeric scale where zero means no pain and that pharmacological interventions are provided in accordance with physician orders; the medication administration policy stated medications should be administered consistent with accepted standards of practice.
Failure to Assess Resident for Physical Restraint Use
Penalty
Summary
The facility failed to ensure that a resident was properly assessed for the use of physical restraints, specifically alarms, which are considered restraints under the facility's policy. The resident in question had a history of falls and was diagnosed with peripheral neuropathy, diabetes mellitus, vascular dementia, anxiety, and hypertension. The resident's Minimum Data Set (MDS) assessment indicated moderately impaired cognition and a need for supervision and assistance with daily activities. Despite the use of bed and chair alarms, there was no documentation of restraint assessments being completed for these devices. Observations confirmed the presence of pressure-sensitive alarms and a pull-tab alarm for the resident, yet the facility did not conduct the necessary restraint assessments as required by their policy. The Corporate Nurse acknowledged that the facility did not consider these alarms as physical restraints, which contradicted the facility's policy defining physical restraints. The policy mandates that restraint assessments be conducted upon admission and as needed, with a physician's order and informed consent obtained, which was not adhered to in this case.
Failure to Implement Fall Interventions
Penalty
Summary
The facility failed to ensure that fall interventions were in place for a resident, as outlined in their comprehensive care plan. The resident, who had a history of falls and was at risk for further incidents, was admitted with medical diagnoses including polyneuropathy, arthritis, Alzheimer's disease, hypertension, atrial fibrillation, and chronic kidney disease. The resident's Minimum Data Set (MDS) assessment indicated moderate cognitive impairment and a need for supervision with certain activities. The care plan, dated over two years prior, specified interventions such as keeping the call light within reach, placing non-skid strips in front of the toilet, and posting visual reminders to call for help. During an observation, it was noted that the resident's room lacked the specified non-skid strips and visual reminders, which were confirmed missing by a State tested Nursing Assistant (STNA). The facility's policy on Fall Management, dated several years earlier, required that a plan be identified and implemented to protect residents from recurrence of falls, and that the care plan should reflect the resident's safety needs and interventions. The absence of these interventions in the resident's environment indicates a failure to adhere to the care plan and facility policy, contributing to the deficiency identified by the surveyors.
Failure to Maintain Intact PEG Tube
Penalty
Summary
The facility failed to ensure that a percutaneous endoscopic gastrostomy (PEG) tube was intact and functioning properly for a resident with multiple medical conditions, including amyotrophic lateral sclerosis (ALS) and dependence on a ventilator. The resident, who was cognitively intact, had a PEG tube for enteral feedings and required substantial assistance with daily activities. A physician's order was in place to flush the PEG tube with water three times daily, and there was an order for non-emergent transport to the hospital for PEG tube replacement. However, during an observation, it was noted that the PEG tube had medical tape wrapped around it, which was slightly soiled, indicating a possible leak or break in the tube. The resident confirmed that the tape was applied due to a hole in the tube, and staff were aware of the issue but continued to use the tube by pinching it off instead of using the provided clamp. Interviews with nursing staff revealed a lack of awareness and communication regarding the condition of the PEG tube. One nurse confirmed the presence of the tape but was unaware of any leakage, while another nurse believed the tape was applied at the hospital. A nurse's note later confirmed that the PEG tube was leaking and could not be replaced in-house, leading to the resident being sent to the hospital for a new tube. The hospital's emergency room note corroborated the malfunction, stating the tube had a crack and was taped. The facility's policy on enteral tube feeding emphasized monitoring for complications and notifying healthcare providers, which was not adequately followed in this case.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that medications were consumed at the time of administration and not left unsecured at the bedside, affecting one resident. During an observation, a registered nurse was found to have left three medication cups with four white tablets on a resident's bedside table. The nurse was unaware of the contents of the medication cups and how long they had been there. The medications were subsequently discarded in the biohazard bin. The resident, who was cognitively intact and had a percutaneous endoscopic gastrostomy tube for enteral feedings, confirmed that the medication cups had been on the bedside table for several days. There was no documentation in the medical record to support a physician's order allowing medications to be left at the bedside. The facility's medication administration policy requires staff to administer medication and remain with the resident while it is swallowed, and prohibits leaving medication in the resident's room without orders to do so.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Centerville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Otterbein Springboro | 1.7 mi | ★★★★★ | 9 | 0 |
| St Leonard Hcc | 3 mi | ★★★★★ | 1 | 0 |
| Centerville Health And Rehab | 3.5 mi | ★★★★★ | 5 | 0 |
| Hillspring Health Care & Rehab | 4 mi | ★★★★★ | 3 | 0 |
| Centerville Post Acute | 4.3 mi | ★★★★★ | 1 | 0 |
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