Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Beavercreek Health And Rehab during CMS and state inspections, most recent first.
Surveyors found that the facility did not maintain hot water temperatures within the policy range of 105–120°F in multiple resident rooms and spa areas, with readings both above 120°F and as low as the 50s and 60s. A CNA reported that water in one spa room was not warm enough to provide showers, and a resident stated she received a cold shower in her room. The Director of Maintenance acknowledged that water temperatures were expected to be within the specified range and confirmed that temperatures were not consistently maintained according to the facility’s water temperature safety policy.
A resident with multiple complex medical conditions was injured during a transfer when a Hoyer lift pad broke, resulting in fractures to both femurs and the spine. Staff interviews revealed that concerns about the poor condition of Hoyer pads had been reported to administration for months without action, and there was no routine inspection plan in place. Only one staff member was actively assisting during the transfer, contrary to policy requiring two, leading to the resident's fall and subsequent hospitalization.
A resident with quadriplegia and polyneuropathy, dependent on staff for care and identified as at risk for pressure ulcers, developed an unstageable pressure ulcer on the left foot. Despite existing care plan interventions, no new measures were implemented after the wound was found, and staff did not conduct further assessment or therapy evaluation to address the pressure source.
Two residents did not receive Repatha injections as ordered due to inconsistent pharmacy deliveries and staff practices of discontinuing and rewriting orders to prompt medication delivery. The DON confirmed that only a portion of the prescribed doses were administered, despite facility policy requiring medications to be given as prescribed.
A resident with multiple chronic conditions was discharged for non-payment without proper documentation of discharge planning, including missing nursing discharge notes and incomplete recapitulation of stay forms. Staff interviews confirmed that required discharge documentation and planning details were not completed or available in the medical record.
A resident with severe cognitive impairment and multiple medical conditions was admitted with deep tissue injuries to the left heel and left outer ankle. Although physician orders for wound care were written several days after admission, staff did not initiate treatment for the pressure ulcers until that time, resulting in a delay of care.
Staff failed to timely report, assess, and investigate a fall involving a resident with dementia and impaired mobility, as required by facility policy, and did not implement fall prevention interventions per the care plan for another resident with hemiplegia. One resident was found on the floor and not properly assessed or reported, while another was left without a required fall mat and with the bed in a high position, contrary to care plan instructions.
A resident with severe cognitive impairment and multiple medical conditions developed a pressure ulcer on the left knee due to the facility's failure to timely assess and treat a newly identified skin issue. Despite being at high risk for skin breakdown, the facility did not document required skin checks or follow through with prescribed wound care. Physical therapy noted a scab and redness, but the knee brace continued to be used until the area became necrotic. The facility's policy on pressure injury prevention was not followed, leading to inadequate treatment of the ulcer.
A resident with severe cognitive impairment and multiple medical conditions did not receive prescribed doses of Morphine Sulfate as ordered. An LPN documented the administration of the medication on the MAR, but the Controlled Drug Record lacked supporting documentation for several doses. The LPN admitted to not administering the medication because the resident was resting, contrary to the facility's policy requiring proper documentation.
A resident with multiple medical conditions, including MRSA, was under Contact Precautions, but a State tested Nursing Assistant (STNA) failed to wear PPE and perform hand hygiene as required by the facility's policy. The STNA mistakenly believed the resident was on Enhanced Barrier Precautions. This breach was identified during a complaint investigation.
The facility failed to serve dairy products at the appropriate temperature, affecting 68 residents. Milk was observed at 46.6°F, above the required 41°F. Dietary staff did not replace the milk on trays already prepared, and these were delivered to residents. A resident noted the milk could have been colder.
The facility failed to store and prepare food under sanitary conditions, affecting 68 residents. Mold was found in the walk-in cooler, and cucumbers were leaking onto potatoes. The walk-in freezer had unsealed food, and the hood vents and sprinklers were coated in a dark gray substance. Facility policies on cleanliness were not followed.
The facility failed to document and follow up on resident concerns raised during Resident Council meetings, affecting several residents. Issues such as snacks not being distributed at night, delayed call light responses, and incomplete showers were consistently raised, but the facility did not provide evidence of discussions or plans to address them. Interviews confirmed that the facility did not follow up timely on these concerns, and management instructed staff not to include detailed notes in meeting minutes.
The facility failed to ensure accurate code status documentation for three residents, leading to discrepancies between paper charts and EMRs. One resident's paper chart indicated a DNR-CCA status, while the EMR showed Full Code. Another resident's paper chart showed DNR-CC, but the EMR listed Full Code. A third resident had mismatched DNR statuses between the EMR and paper chart. These inconsistencies were confirmed by an LPN and the DON.
A facility failed to maintain a safe and homelike environment for a resident with multiple health conditions, including COPD and heart failure. A large hole was found in the drywall behind the resident's bariatric bed, which the Maintenance Director confirmed had not been reported. The damage was significant, requiring more than a simple patch to repair.
The facility failed to notify three residents and their representatives of the reasons for hospital transfers, as required by policy. One resident with multiple complex diagnoses and two others with serious health conditions were transferred without documented notification. Staff interviews confirmed the lack of written notifications, despite the facility's policy mandating timely notice before transfers.
The facility failed to provide timely bed hold notifications to residents upon hospital transfer, affecting three residents. A resident with osteomyelitis and heart failure, another with cerebral palsy and diabetes, and a third with acute respiratory failure and multiple sclerosis were all given bed hold notices only after their hospital stays. The DON and Business Office Manager confirmed this practice, which was against the facility's policy requiring notification within 24 hours of emergency transfer.
A resident with dementia and oropharyngeal dysphagia was not provided with a lid for their provale cup, despite it being ordered and indicated on the meal ticket. The Dietary Manager confirmed the absence of the lid, stating it was not typically provided as the resident did not like using it. The facility's policy required that adaptive devices be provided for residents who need them.
The facility failed to maintain resident dignity, affecting two residents. One resident, who required assistance with eating, was left without lunch while others ate, and another resident had a full foley catheter bag visible from the hallway without a dignity cover. These incidents were confirmed by staff interviews and violated the facility's dignity policy.
A resident was refused re-admission to a facility after hospitalization despite being deemed stable by the ER. The facility's DON and staff cited critical lab results as the reason for refusal, leading to the resident's return to the hospital. Interviews revealed inadequate documentation and communication regarding the decision, contrary to facility policy.
A resident with a history of falls was found on the floor by an STNA, claiming to have sat down intentionally. The RN did not report or document the incident, leading to a lack of monitoring. Later, the resident reported hip pain, and an X-ray revealed a fracture, requiring hospital evaluation and surgery.
Failure to Maintain Consistent Safe Hot Water Temperatures
Penalty
Summary
The facility failed to maintain hot water temperatures within its policy range of 105 to 120 degrees Fahrenheit in resident rooms, spa rooms, and common bathing areas, based on multiple observations over several days. On 02/17/26, surveyors measured water at 99.2°F in the Red spa room and above 120°F in several resident rooms (105, 108, 205, 216, 307, 308, 310, and 315). The Director of Maintenance stated that water temperatures were expected to be kept between 105°F and 120°F throughout the facility. On 02/18/26, additional observations showed inconsistent temperatures, including resident rooms with water at 106°F, 116°F, 110°F, 82°F, and 52°F. The Red spa room sink measured 110°F and its shower 98°F, while the Blue spa room sink measured 80°F and its shower 65°F. On 02/18/26, a CNA confirmed that water temperatures in the Blue spa room were not warm enough to provide showers and reported that maintenance had been working on the issue all day. On 02/19/26, a resident reported receiving a cold shower in her room. Subsequent measurements that same day showed water temperatures of 57°F in one resident room, 88.1°F in the Blue spa shower and 82°F in its sink, and 62°F and 59°F in additional resident rooms. In a follow-up interview on 02/19/26, the Director of Maintenance verified that water temperatures were not consistently maintained within the safe and appropriate range throughout the building. Review of the facility’s “Safety of Water Temperatures” policy dated 12/2009 confirmed that water supplies to resident rooms, bathrooms, common areas, and tub/shower areas were to be maintained between 105°F and 120°F. This deficiency was investigated under Complaint Number 2724861.
Failure to Maintain Safe Transfer Equipment Resulting in Resident Injury
Penalty
Summary
The facility failed to ensure a safe transfer for a resident using a mechanical Hoyer lift, resulting in actual harm. The incident occurred when a staff member attempted to transfer a resident with significant medical needs, including cerebral palsy, diabetes with polyneuropathy, morbid obesity, and heart failure. During the transfer, the Hoyer pad strap broke, causing the resident to fall and sustain bilateral femur fractures and an L1 compression fracture, which required hospitalization and surgical intervention. Multiple staff interviews confirmed that the Hoyer pads were in poor condition prior to the incident, with several staff members having reported their concerns to administration over a period of months. Despite these repeated reports, no action was taken by management to replace the defective equipment until after the resident's fall. Staff also confirmed that the facility did not have a routine inspection plan in place for the Hoyer pads before the incident occurred. Facility policy required that two nursing assistants be present for mechanical lift transfers and that all equipment be in good condition. On the day of the incident, only one staff member was actively assisting with the transfer, while the second was present in the room but not directly involved at the time of the fall. The lack of timely equipment maintenance and failure to follow established safety protocols directly contributed to the resident's injury.
Failure to Assess and Implement Interventions After Discovery of Pressure Ulcer
Penalty
Summary
The facility failed to assess and implement new interventions after an unstageable pressure ulcer was discovered on a resident's left foot. The resident, who was admitted with diagnoses including quadriplegia and polyneuropathy, was dependent on staff for bathing, dressing, and positioning, and was identified as being at risk for pressure ulcers. Despite care plan interventions such as weekly skin checks, floating heels, turning and repositioning, and use of pressure-reducing devices, a wound was found on the ball of the resident's left foot during a bed bath. Documentation indicated instructions to relieve pressure and contact the primary care provider, and the resident reported that the wheelchair footrest may have caused the wound due to lack of sensation in her legs. Observations and interviews revealed that no new interventions were implemented to alleviate pressure from the affected foot after the ulcer was found. The resident was seen in her wheelchair without a pillow under her foot, and both nursing and administrative staff confirmed that neither a therapy evaluation nor additional interventions had been initiated. There was also uncertainty among staff regarding the cause of the wound, with suggestions that either the bed bolsters or the wheelchair foot pedals could be responsible. The facility's policy required assessment and documentation of significant risk factors for pressure sores, but this was not followed after the wound was identified.
Failure to Administer Medications per Physician Orders Due to Pharmacy Delivery Issues
Penalty
Summary
The facility failed to administer medications according to physician orders for two residents who were prescribed Repatha (Evolocumab) for hyperlipidemia and hypertriglyceridemia. For one resident with diagnoses including type II diabetes mellitus with foot ulcer and chronic heart failure, physician orders specified Repatha injections every three weeks, but review of the Medication Administration Records (MAR) and pharmacy delivery slips showed that only five of thirteen ordered doses were administered between March and November. The Director of Nursing (DON) confirmed that the medication was not consistently delivered by the pharmacy as ordered, and when the medication was unavailable, staff would sometimes discontinue and rewrite orders to prompt delivery. Only eight doses were documented as delivered by the pharmacy during this period. Another resident with multiple diagnoses, including respiratory failure, diabetes with polyneuropathy, and chronic heart failure, was ordered Repatha injections every two weeks. Review of records indicated that only four of eleven ordered doses were administered, with only five doses documented as delivered by the pharmacy. The DON confirmed that the medication was not administered as ordered due to delivery issues, and similar to the first case, staff would discontinue and rewrite orders to facilitate delivery. Facility policy required medications to be administered safely, timely, and as prescribed, but this was not followed in these cases.
Failure to Document Discharge Planning and Required Notifications
Penalty
Summary
The facility failed to document discharge planning for a resident who was admitted with multiple diagnoses, including chronic obstructive pulmonary disease, atherosclerotic heart disease, anxiety disorder, hypertension, osteoarthritis, and depression. The resident was admitted for a short-term stay and expressed a desire to return home safely, as reflected in her care plan. Despite a 30-day discharge notice being issued due to non-payment and a physician's order for discharge to home with hospice care, there was no documentation in the progress notes regarding the resident's discharge. Additionally, the recapitulation of stay form was incomplete, with only the sections on mobility and activities of daily living filled out, and no nursing discharge note was present in the medical record. Interviews with facility staff confirmed that required documentation was missing. The Assistant Director of Nursing acknowledged that a nursing discharge note and a fully completed recapitulation of stay form should have been present. The Administrator confirmed the resident was discharged to her sister's home but was unsure about the discharge planning process. The former Social Worker stated she was not present at the time of discharge and was uncertain about the arrangements made for home health care and therapy, as she was no longer employed at the facility when the discharge occurred.
Delayed Pressure Ulcer Treatment
Penalty
Summary
A deficiency occurred when staff failed to timely initiate treatment for pressure ulcers in a resident with multiple medical conditions, including a stage four pressure ulcer, stroke, liver cirrhosis, and depression. The resident was admitted with deep tissue injuries to the left heel and left outer ankle, both measuring two centimeters in length and width, but the depth was not measured. Although physician orders to cleanse the wounds and apply skin prep every shift were written on the third day after admission, treatment was not started until that time, resulting in a delay of care. Staff confirmed that the prescribed treatment for the pressure ulcers was not initiated upon admission, despite the resident's dependence on staff for activities of daily living and severely impaired cognition. Online clinical guidance indicates that immediate treatment is required once a pressure ulcer develops.
Failure to Report, Assess, and Prevent Resident Falls
Penalty
Summary
The facility failed to ensure timely reporting, assessment, and investigation of resident falls, as well as implementation of fall prevention interventions according to resident care plans. For one resident with multiple comorbidities including dementia, chronic pain, and impaired balance, video footage showed the resident on the floor beside her bed, with a CNA attempting to lift her back onto the bed without reporting the fall to a nurse. The resident was wearing socks, which contributed to difficulty in the transfer. The incident was not reported by staff, and the facility's investigation was incomplete, lacking a statement from the involved CNA and unable to determine the circumstances due to delayed reporting. The facility's policy required staff to evaluate and document falls, and for nurses to assess and document injuries and circumstances, which was not followed in this case. Another resident with hemiplegia, weakness, and impaired balance was found in bed with the bed in the highest position and without a required fall mat on one side, contrary to the care plan interventions. Staff were unsure about the need for fall mats on both sides and confirmed the absence of the mat. These failures affected two of three residents reviewed for falls and demonstrate noncompliance with accident hazard prevention and supervision requirements.
Failure to Timely Assess and Treat Pressure Ulcer
Penalty
Summary
The facility failed to provide timely assessment and treatment for a newly identified skin issue in a resident, leading to the development of a pressure ulcer. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was admitted with multiple medical diagnoses including nontraumatic intracerebral hemorrhage and vascular dementia. Initially, the resident did not have a pressure ulcer, but a physician's order was in place to monitor the skin on the left knee due to the use of a knee brace. However, the facility did not document the completion of skin checks on several occasions in October, despite the resident being at high risk for skin breakdown. Physical therapy notes indicated that a scab and redness were observed on the resident's left knee as early as mid-October, and the nurse was notified. Despite this, the facility continued to apply the knee brace until the end of October, when the area was noted to be more inflamed and necrotic. Weekly skin assessments failed to identify any issues until the end of October, when an unstageable pressure ulcer was documented. The facility's Treatment Administration Record for November also lacked documentation of wound care on multiple dates, indicating a failure to follow through with the prescribed treatment regimen. Interviews with facility staff confirmed the lack of documentation and awareness of the resident's skin breakdown until after the end of October. The facility's policy on the prevention of pressure injuries emphasized the importance of daily skin inspections and careful selection and monitoring of medical devices to prevent tissue damage. However, the facility did not adhere to these guidelines, resulting in the development and inadequate treatment of a pressure ulcer on the resident's left knee.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure medications were administered as ordered for Resident #75, who was affected by this deficiency. Resident #75 had multiple medical diagnoses, including chronic obstructive pulmonary disease, heart failure, atrial fibrillation, dementia with psychosis, paranoid schizophrenia, and diabetes mellitus. The resident was enrolled in Hospice services and had severe cognitive impairment, requiring substantial assistance for daily activities. A physician order was in place for Morphine Sulfate (MSO4) to be administered three times daily for pain or shortness of breath. However, the Medical Administration Record (MAR) indicated that the MSO4 was documented as administered, but the Controlled Drug Record lacked documentation to support the administration of the 2:00 P.M. doses on several specified dates. Licensed Practical Nurse (LPN) #155 confirmed during an interview that she documented the administration of the 2:00 P.M. doses of MSO4 on the MAR, despite not actually administering the medication because the resident was usually sleeping or resting comfortably at those times. The facility's policy on medication administration required that medications be administered as prescribed and documented appropriately if withheld or refused. The LPN acknowledged not documenting the reason for not administering the medication in a progress note, which was contrary to the facility's policy. This deficiency was investigated under Complaint Number OH00158451.
Infection Control Breach for Resident on Contact Precautions
Penalty
Summary
The facility failed to adhere to infection control procedures for a resident under Contact Precautions, affecting one out of three residents reviewed for wound care. The resident, who was cognitively intact, had multiple medical diagnoses including alcoholic cirrhosis of the liver, chronic obstructive pulmonary disease, chronic Hepatitis C, and was a carrier or suspected carrier of MRSA. The resident had physician orders for Contact Precautions and specific wound care treatments due to vascular ulcers on various parts of the body. Despite these precautions, a State tested Nursing Assistant (STNA) entered the resident's room without donning personal protective equipment (PPE) and failed to perform hand hygiene after exiting, which was against the facility's policy for Contact Precautions. The STNA mistakenly believed the resident was only on Enhanced Barrier Precautions, not Contact Precautions. The facility's policy required staff and visitors to wear gloves and gowns when entering the room of a resident under Contact Precautions and to perform hand hygiene before leaving. The President of Clinical confirmed that the medical record did not document MRSA colonization and acknowledged the resident's refusal of treatment at times, preferring to perform wound care independently. This incident was identified during a complaint investigation, highlighting a lapse in following established infection control protocols.
Inadequate Temperature Control of Dairy Products
Penalty
Summary
The facility failed to ensure that dairy products were served at the appropriate temperature, potentially affecting 68 residents. During an observation in the dining area, it was noted that trays containing meals and milk cartons were lined up for delivery. The milk on one resident's tray was found to be at 46.6 degrees Fahrenheit, which is above the facility's policy requirement of 41 degrees or below. Dietary Aid #349 confirmed the temperature and admitted to not knowing the correct serving temperature for milk. Despite identifying the issue, the dietary staff did not replace the milk on four trays that were already on the cart, and these trays were subsequently delivered to residents. The Dietary Manager confirmed that milk should be maintained at 41 degrees Fahrenheit or less and stated that milk was placed in the freezer 30 minutes before being brought to the unit. A resident expressed that the milk received at breakfast could have been colder, indicating dissatisfaction with the temperature of the served milk.
Food Storage and Preparation Deficiencies
Penalty
Summary
The facility failed to ensure food was stored and prepared in a manner that prevents the potential spread of foodborne illness, affecting 68 residents. During an observation of the facility's walk-in cooler, gray and white speckled areas, identified as mold, were found throughout the shelves and milk crates. A puddle of brown liquid was observed on the floor beneath a box of potatoes, which was being contaminated by leaking cucumbers from the shelf above. Dietary Staff confirmed the presence of mold and the leaking cucumbers. The Dietary Manager stated the cooler had been recently cleaned, but the mold was attributed to a dirty fan, which had been cleaned by the Maintenance Director a month prior. Additionally, the walk-in freezer contained two open and unsealed boxes of vegetable protein loafs, exposing the food to air. The hood vents and sprinklers above the stove were coated in a dark gray fuzzy substance, indicating a lack of cleaning since May. The facility's policies on food storage and service, which require cleanliness and sanitary conditions, were not adhered to, as evidenced by the observations of spills, leaks, and unclean equipment.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to document and follow up on resident concerns raised during Resident Council meetings, affecting seven residents who participated in these meetings. The residents, most of whom were cognitively intact, expressed concerns about various issues, including dietary snacks, nursing call lights, showers, and housekeeping. Despite these concerns being consistently raised in meetings, the facility did not provide documented evidence of discussions or plans to address them. The review of Resident Council meeting minutes from August 2023 to August 2024 revealed a lack of documentation regarding the concerns brought up by residents and the facility's plans to address them. Specific issues such as snacks not being distributed at night, delayed call light responses, and incomplete showers were noted, but the action taken sections of the concern forms were often left blank. Additionally, there was no evidence of follow-up actions, such as staff education or audits, being completed as indicated in the meeting minutes. Interviews with residents and staff confirmed that the facility did not follow up timely on the concerns raised. Residents reported that the same issues were brought up repeatedly without resolution, and they were not provided with detailed meeting notes. The Activity Director acknowledged taking detailed notes during meetings but stated that management instructed her not to include them in the minutes. The facility's inability to locate additional concern forms and documented evidence of follow-ups further highlighted the deficiency in addressing resident grievances.
Inaccurate Code Status Documentation in Medical Records
Penalty
Summary
The facility failed to ensure the accuracy of code status in the medical records for three residents, which could potentially affect all 70 residents in the facility. For Resident #58, there was a discrepancy between the Do Not Resuscitate (DNR) order form in the paper chart, which indicated a DNR-Comfort Care-Arrest (CCA) status, and the electronic medical record (EMR), which showed a Full Code status. This inconsistency was confirmed by an LPN who stated that she would most likely refer to the EMR to check a resident's code status. Similarly, Resident #32's medical records showed a mismatch between the paper chart, which indicated a DNR-Comfort Care (CC) status, and the EMR, which listed a Full Code status. This discrepancy was verified by the same LPN. For Resident #29, the EMR indicated a DNR-CC status, while the paper chart had an undated DNR form showing DNR-CC-A. The Director of Nursing confirmed the mismatch in Resident #29's code status. The facility's policy on advance directives stated that residents' wishes should be communicated to direct care staff and physicians by placing the documents in a prominent, accessible location in the medical record.
Failure to Maintain a Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for a resident, as required by their policy. The deficiency was identified during an observation where a large hole was found in the drywall behind the resident's bariatric bed. The damage was approximately six inches by 18 inches in size. The Maintenance Director confirmed the damage and stated that he had not been informed of it. He also noted that the damage was significant enough that a simple patch would not suffice, and a larger section of drywall would need to be replaced. The resident involved had multiple diagnoses, including COPD, diabetes, dysphagia, heart failure, unspecified psychosis, respiratory failure, and morbid obesity.
Failure to Notify Residents of Hospital Transfer Reasons
Penalty
Summary
The facility failed to provide timely notification to residents and their representatives regarding the reason for transfer to the hospital, affecting three residents. Resident #43, with diagnoses including osteomyelitis of vertebra, heart failure, and kidney failure, was hospitalized multiple times without documented evidence of notification for the reason of transfer. Similarly, Resident #56, diagnosed with cerebral palsy, diabetes, and heart failure, was hospitalized without receiving a notification for the reason of transfer. Additionally, Resident #21, who had multiple complex diagnoses such as acute respiratory failure, severe sepsis, and multiple sclerosis, was transferred to the hospital without documented evidence of notification to the resident or their representative. Interviews with facility staff, including the Regional Director of Operations and the Business Office Manager, confirmed the absence of written notifications for these transfers. The facility's policy on transfer or discharge, dated 10/2022, requires that a notice of transfer be issued as soon as practicable before the transfer, which was not adhered to in these cases.
Failure to Provide Timely Bed Hold Notifications
Penalty
Summary
The facility failed to provide timely bed hold notifications to residents or their representatives upon transfer to a hospital, affecting three residents. Resident #43, with diagnoses including osteomyelitis of vertebra, heart failure, and kidney failure, was hospitalized twice, and in both instances, the bed hold notice was provided only upon discharge from the hospital, not at the time of admission. Similarly, Resident #56, diagnosed with cerebral palsy, diabetes, and heart failure, was hospitalized, and the bed hold notice was also given post-discharge. The Director of Nursing confirmed that the notices were issued after the hospital stays ended. Resident #21, with a complex medical history including acute respiratory failure, severe sepsis, and multiple sclerosis, was transferred to the hospital and readmitted to the facility. The bed hold notice for this resident was signed and dated after the hospital stay, indicating it was not provided at the time of transfer. The Business Office Manager verified that the facility's practice was to issue bed hold notices following hospital stays, contrary to the facility's policy requiring notification within 24 hours of emergency transfer.
Failure to Provide Adaptive Equipment as Ordered
Penalty
Summary
The facility failed to provide adaptive equipment as ordered for a resident with dementia and oropharyngeal dysphagia. The resident was admitted with a diagnosis that included severely impaired cognition and was assessed as independent with the use of a provale cup for safe intake of thin liquids. A physician order specified the use of a provale cup as part of the resident's dysphagia mechanical soft diet. The plan of care also included the provision of a provale cup due to the resident's physical functioning deficit related to impaired mobility and cognition. During an observation, the resident was found with a provale cup without a lid, despite the meal ticket indicating the need for a 10 CC provale cup with a lid. The resident confirmed the absence of the lid, and the Dietary Manager verified that the lid was not provided because the resident reportedly did not like using it. The Dietary Manager was unable to locate the lid in the dietary service area, acknowledging that adaptive equipment should be provided if listed on the meal ticket. The facility's policy stated that adaptive devices, including specialized cups, should be provided for residents who need them.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to treat all residents with dignity and respect, affecting two residents. Resident #28, who was severely cognitively impaired and required substantial assistance with eating, was observed in the dining room without being served lunch while other residents were eating. Despite being present in the dining room from 11:30 A.M. to 12:10 P.M., Resident #28 was not served until 12:25 P.M. after a State Tested Nursing Assistant (STNA) intervened. The resident expressed hunger and ate 75 percent of his meal once it was provided. Resident #29, who had multiple diagnoses including osteomyelitis and chronic pulmonary disease, was observed with a full foley catheter bag visible from the hallway without a dignity cover. The facility's policy required privacy covers for catheter bags, but this was not adhered to, as confirmed by interviews with an STNA and the facility's Administrator and Director of Nursing. This deficiency was investigated under Complaint Number OH00157658.
Facility Refusal to Re-admit Resident Post-Hospitalization
Penalty
Summary
The facility failed to allow a resident to return to the nursing home in a timely manner following a hospital stay, which affected one of four residents reviewed for hospitalization. The resident, who had been admitted with diagnoses including osteomyelitis of the vertebra, heart failure, cellulitis, kidney failure, and edema, was hospitalized due to critical laboratory findings. Upon stabilization and treatment at the hospital, the resident was deemed fit for discharge back to the facility by the ER physician. However, the facility's Director of Nursing (DON) refused to accept the resident back, citing the resident's condition as too critical for their care, despite the hospital's assessment of stability. The ER notes detail multiple attempts by hospital staff to communicate with the facility regarding the resident's condition and readiness for discharge. The ER physician and nurses repeatedly confirmed the resident's stability and appropriateness for nursing facility care, yet the facility's DON and staff refused to accept the resident, leading to the resident being sent back to the hospital shortly after initial discharge. The facility's refusal was based on elevated lab results, which the facility's physician and DON interpreted as indicating instability, despite the hospital's contrary assessment. Interviews with facility staff, including the LPN on duty and the Regional Director of Operations, revealed a lack of documentation and communication regarding the decision to refuse the resident's return. The facility's physician was not present during the incident and had limited communication with the DON. The facility's policy on transfer and discharge requires efforts to ascertain the resident's condition and needs through communication with hospital staff, which was not adequately followed in this case. The deficiency was investigated under a specific complaint number, highlighting non-compliance with regulatory requirements.
Failure to Communicate Resident Fall Incident
Penalty
Summary
The facility failed to ensure proper communication between nursing staff regarding a resident incident that was later determined to be a fall. A resident with a history of anxiety disorder, right femur fracture, atrial fibrillation, hypertension, and repeated falls, was found on the floor by a state-tested nursing assistant (STNA) in the early morning. The resident claimed to have intentionally sat on the floor to avoid falling due to forgetting her walker. The registered nurse (RN) on duty did not report this incident to the oncoming licensed practical nurse (LPN) and did not document the incident until his next shift. The RN did not consider the incident a fall because the resident stated she sat on the floor intentionally. Consequently, the RN did not communicate the incident to the oncoming LPN, who was unaware of the situation when she began her shift. Later, the resident reported pain in her hip, which led to an X-ray revealing a right hip fracture. The resident was subsequently sent to a local hospital for evaluation and required surgery to repair the fracture. The facility's policy on managing falls and fall risks requires staff to monitor and document each resident's response to interventions intended to reduce falling or the risk of falling. However, the RN's failure to report and document the incident promptly resulted in a lack of ongoing monitoring and potentially contributed to the resident's injury. This deficiency was identified during a survey and was part of a complaint investigation.
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 584 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
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 Beavercreek
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Widows Home Of Dayton | 1.9 mi | ★★★★★ | 4 | 0 |
| Sanctuary At Wilmington Place | 3 mi | ★★★★★ | 1 | 0 |
| Beavercreek Post Acute | 3.8 mi | ★★★★★ | 0 | 0 |
| Gem City Healthcare And Rehabilitation Center | 4.3 mi | ★★★★★ | 9 | 0 |
| Dunbar Health & Rehab Center | 4.5 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Beavercreek Health And Rehab.
100% money-back within 48 hours.
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.