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 Post Acute during CMS and state inspections, most recent first.
A resident with a history of constipation experienced abdominal and rectal pain due to infrequent bowel movements. Despite complaints and requests for help, facility staff failed to notify medical personnel, resulting in the resident being treated for fecal impaction at a hospital. The facility lacked proper communication and documentation regarding the resident's condition.
The facility failed to maintain proper kitchen sanitation and food storage, affecting all residents except one. Observations revealed dirt, rust, and unidentified substances in various kitchen areas, along with improperly stored food items. These issues were confirmed by the Dietary Manager, indicating non-compliance with the facility's policies on food storage and sanitization.
The facility failed to follow prescribed menu portion sizes and did not have menus reviewed by a dietitian, affecting all residents except one. Observations showed incorrect portion sizes for scrambled eggs and pureed diets. Additionally, residents were not given choices for breakfast meals, affecting three cognitively intact residents who confirmed they could not choose breakfast options. This deficiency was investigated under two complaint numbers.
The facility failed to provide adequate staffing, resulting in delayed care and medication administration for several residents. A resident with severe cognitive impairment waited nearly 30 minutes for assistance, while multiple residents experienced significant delays in receiving their medications due to insufficient nursing staff. The facility did not adhere to its policies on staffing and timely medication administration, as revealed during the investigation of multiple complaints.
The facility failed to properly prepare pureed eggs and bread for residents on pureed diets, resulting in food with chunks that were not smooth as required. This affected four residents, and the Dietary Manager confirmed the oversight during an interview.
A resident experienced a significant weight loss of 7.5% over 33 days, but the facility failed to notify the physician or provider. The resident, who was severely cognitively impaired and required assistance with eating, was not reported to the physician despite the facility's policy requiring such notification for significant changes in condition.
A resident received unnecessary Mupirocin ointment beyond the prescribed period due to a lack of communication and adherence to medication administration policies. The ointment was applied to the resident's penis despite no wound being present, and staff interviews confirmed the medication should have been discontinued earlier.
A resident with a documented egg allergy was served scrambled eggs by a staff member, despite clear dietary restrictions noted in the resident's medical records and meal ticket. The resident, who is moderately cognitively impaired, confirmed the allergy and experienced symptoms of an allergic reaction. Interviews with staff confirmed the oversight.
The facility failed to respond promptly to a resident's call light, leaving them without assistance for 24 minutes, and did not fulfill a request for ice water due to staff limitations. Additionally, the automatic door opener was not functioning, affecting a resident's ability to exit the facility. These issues highlight noncompliance with facility policies and standards.
The facility failed to provide adequate ADL assistance for two residents. One resident with hemiplegia experienced a delay in receiving incontinence care, while another resident with chronic conditions was not offered regular showers, receiving only two bed baths in a month. These actions were inconsistent with the facility's policy on promoting cleanliness and comfort.
The facility failed to administer medications as ordered for two residents, resulting in missed doses of Pregabalin due to unavailability and delayed pharmacy delivery. Despite staff and pharmacy awareness, the medications were not provided in a timely manner, violating facility policies on medication administration.
A structural deficiency was identified in the facility after a vehicle struck the building, creating a hole in the exterior wall covered with plastic. The incident occurred around Thanksgiving, and the facility was initially waiting for the car owner's insurance to cover the damage. However, the insurance did not cover it, and the facility's corporate office is now involved. Despite an inspection by the insurance company, no repair estimates have been completed, and the facility lacks a policy for such repairs.
The facility failed to have an RN on duty for eight consecutive hours on a Sunday, as required by CMS and state staffing regulations. This deficiency was confirmed through staff punches and an interview with the Administrator, potentially affecting all 78 residents.
The facility failed to ensure that residents were free from significant medication errors, affecting two residents. One resident did not receive her prescribed cancer medication on two occasions, and another resident did not receive his prescribed fentanyl patch on one occasion due to unavailability. There was no documentation that the physicians were notified about the unavailability of the medications.
Failure to Timely Address Resident's Constipation
Penalty
Summary
The facility failed to properly and timely assess a resident for a change in condition, resulting in actual harm. The resident, who was cognitively intact and required assistance with activities of daily living, had a history of constipation and was on medications including oxycodone for pain and Miralax and Senokot for constipation. Despite these measures, the resident experienced constipation with abdominal and rectal pain, which was not adequately addressed by the facility staff. The resident's bowel movement log indicated infrequent and small bowel movements over a period of several weeks. Despite the resident's complaints of pain and requests for assistance, the facility staff did not notify the physician or nurse practitioner about the resident's condition. The resident was eventually taken to the hospital, where a fecal impaction was manually removed, and further treatment was administered. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's bowel movements and condition. The facility did not have standing orders or a clinical protocol related to bowel movements, and staff failed to notify medical personnel when the resident's condition did not improve. This deficiency was investigated under a specific complaint number, highlighting the facility's noncompliance with its policy on changes in a resident's condition.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen and food items in a manner that prevents foodborne illness, affecting all residents except one who did not receive food by mouth. During an observation of the kitchen, several sanitation concerns were noted, including built-up dirt behind the dishwasher, rust in the garbage disposal, and splashes of an unidentified substance on the walls. Additionally, there were rusty and dusty vents above the steam table area, cobwebs on the kitchen window, and an open rusted drain on the floor. The handwashing sink had a white substance running down it, and all kitchen walls had splashes of a substance from top to bottom. These observations were confirmed by the Dietary Manager. Further observations revealed additional sanitation issues, such as a black area on the ceiling above the three-compartment sink, standing water in the handwashing sink, and a gray fuzzy substance on an air vent. There was also black and white buildup on the floors, a gray substance on a shelf above the stove, and a black substance on the juice dispenser nozzle. In the dry storage area, an open package of uncooked pasta was found, and in the walk-in refrigerator, undated and uncovered pans of peas and spinach were observed. The facility's policies on food storage and kitchen sanitization were not adhered to, as confirmed by the Dietary Manager.
Deficiency in Menu Portion Sizes and Resident Meal Choices
Penalty
Summary
The facility failed to adhere to the prescribed menu portion sizes and did not have the menus reviewed by a dietitian in advance, affecting all residents except one who received no food by mouth. Observations revealed that residents on regular and mechanical soft diets were served smaller portions of scrambled eggs than specified in the menu, and pureed diets were also served with incorrect portion sizes. The Dietary Manager confirmed these discrepancies and acknowledged that the dietitian had not reviewed the meal spreadsheets for the specified dates, contrary to the facility's policy requiring dietitian approval. Additionally, the facility did not provide residents with choices for breakfast meals, affecting three residents who were cognitively intact and expressed their inability to choose breakfast options. Interviews with residents and staff confirmed that while lunch and dinner choices were provided, breakfast options were not offered, a change attributed to the facility's decision to streamline meal choices. This deficiency was investigated under two complaint numbers, indicating a broader issue with meal planning and resident choice within the facility.
Inadequate Staffing Leads to Delayed Care and Medication Administration
Penalty
Summary
The facility failed to provide adequate staffing to meet the needs of its residents, as evidenced by multiple instances of delayed care and medication administration. Resident #61, who is severely cognitively impaired and dependent on staff for activities of daily living, was observed waiting for assistance for nearly 30 minutes after activating the call light. The resident expressed frustration over the frequent delays in receiving help, which was corroborated by a Certified Nurse Aide (CNA) who admitted to being responsible for 20 residents due to a scheduling error that left the facility short-staffed. Additionally, the facility did not have enough nursing staff to administer medications in a timely manner. On a particular day, several residents, including Residents #33, #28, #32, #59, #14, #52, #51, #31, #46, and #186, experienced significant delays in receiving their scheduled medications. Interviews with nursing staff revealed that the facility was operating with fewer nurses than required, as one nurse called off and another was occupied with training a new nurse, leaving only three nurses to manage the care of 95 residents. The facility's policies on staffing and medication administration were not adhered to, resulting in unmet care needs and delayed medication administration. The staffing schedule was not adjusted to accommodate the absence of a nurse, and the facility's policy of administering medications in a timely manner was not followed. These deficiencies were identified during the investigation of multiple complaints, highlighting the facility's failure to ensure adequate staffing and timely care for its residents.
Improper Preparation of Pureed Diets
Penalty
Summary
The facility failed to ensure that pureed eggs and pureed bread were prepared in a form suitable to meet the needs of residents on pureed diets. This deficiency affected four residents who were identified as receiving pureed diets. During an observation in the kitchen, it was noted that the pureed scrambled eggs contained dime-sized chunks of eggs, and the pureed bread had chunks approximately one quarter inch in diameter. An interview with the Dietary Manager confirmed that the pureed eggs and bread were not blended until smooth, as required by the facility's recipes. The dietary spreadsheet and facility recipes indicated that the eggs and bread should have been processed until smooth, but this was not adhered to, leading to the deficiency.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the resident's physician of a significant weight loss in one of the residents, identified as Resident #40. This resident was admitted with multiple diagnoses, including coronary artery disease, heart failure, diabetes, dementia, and aphasia. The resident was severely cognitively impaired and required assistance with eating. A review of the resident's weight records showed a significant weight loss of 7.5% over 33 days, from 133 pounds to 123 pounds. However, the progress notes from March 12 to March 17 did not document any notification to the physician or provider about this significant weight loss. Interviews conducted on March 17 with the Nurse Practitioner and the Dietician confirmed that they had not been informed of the resident's weight loss. The facility's policy on changes in a resident's condition, dated February 2021, requires prompt notification of the resident's physician and representative when there is a significant change in the resident's medical or mental condition. The policy defines a significant change as a major decline or improvement that would not resolve without staff intervention. The failure to notify the physician of the resident's significant weight loss represents a deficiency in adhering to this policy.
Failure to Discontinue Unnecessary Medication
Penalty
Summary
The facility failed to ensure that Resident #43 did not receive unnecessary medications, specifically Mupirocin ointment. The resident, who was admitted with diagnoses including hemiplegia, hemiparesis following cerebral infarction, vascular dementia, and anxiety disorder, was identified to have a fungal wound on the scrotum. A physician's order was given to apply Mupirocin ointment to the scrotum and tip of the penis every shift. However, the wound progress note later specified that the ointment should be applied twice daily for seven days and then discontinued. Despite this, the Medication Administration Records showed that the ointment was applied to the resident's penis beyond the prescribed period, up until March 2024. Interviews with staff revealed a lack of awareness and communication regarding the wound's location and the medication's stop date. An LPN confirmed that the Mupirocin ointment should have been discontinued by the end of December 2024, indicating that the continued application was unnecessary. The facility's policies on administering medications and antibiotic stewardship were not adhered to, as the medication was not administered in accordance with the prescriber's orders, and there was a failure to ensure the antibiotic had a documented stop date.
Resident Served Allergen Despite Known Allergy
Penalty
Summary
The facility failed to ensure that a resident with a known egg allergy was not served food containing eggs. Resident #7, who was moderately cognitively impaired and required assistance with eating, was admitted with several diagnoses including a displaced intertrochanteric fracture of the left femur, chronic obstructive pulmonary disease, type two diabetes mellitus, vascular dementia, and congestive heart failure. The resident's medical records, including the Minimum Data Set (MDS) assessment and nutritional care plan, clearly indicated an allergy to eggs. Despite this, during a meal preparation observation, a staff member added scrambled eggs to the resident's plate, contrary to the dietary restrictions noted on the meal ticket. Interviews with the staff member who prepared the meal and the registered dietitian confirmed the resident's egg allergy and acknowledged the error in serving eggs. Additionally, the resident herself confirmed her allergy and described experiencing symptoms consistent with an allergic reaction when consuming eggs. This incident highlights a lapse in the facility's adherence to dietary restrictions and protocols, resulting in the resident being exposed to an allergen that could have serious health implications.
Failure to Respond Timely to Resident Requests and Maintain Door Opener
Penalty
Summary
The facility failed to respond to resident requests in a timely manner, as evidenced by the case of a resident with severe cognitive impairment and dependency on staff for activities of daily living. The resident's call light was activated for 24 minutes without response, during which the resident repeatedly called for assistance. When a CNA finally responded, the resident requested ice water, but the CNA left without fulfilling the request due to not knowing the code to access the ice room. Another CNA, responsible for 20 residents, was unable to assist promptly due to other care duties. The facility's policy requires immediate response to call lights and fulfillment of requests within five minutes, which was not adhered to in this instance. Additionally, the facility failed to maintain the automatic door opener for the front door, affecting a resident with cognitive intactness who required assistance with activities of daily living. The resident confirmed the push button to open the door was not functioning, which was corroborated by a Corporate Registered Nurse. The resident reported previous instances of the button not working, indicating a recurring issue. This deficiency was investigated under specific complaint numbers, highlighting noncompliance with facility standards.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for two residents, leading to deficiencies in care. Resident #43, who has hemiplegia and hemiparesis following a cerebral infarction, was observed with an activated call light for 14 minutes without receiving assistance. During this time, the resident's incontinence brief became saturated with urine, and the resident confirmed the delay in receiving care. A Certified Nursing Aide acknowledged the delay and the resident's need for incontinence care, citing an inability to attend to the resident promptly. Resident #69, diagnosed with chronic obstructive pulmonary disease, congestive heart failure, and type two diabetes mellitus, was not offered regular showers as required. The resident's medical records indicated only two bed baths were provided over a month, with no refusals documented. The resident confirmed the lack of regular bathing, and a Licensed Practical Nurse corroborated the infrequent bathing schedule. The facility's policy on bathing, which aims to promote cleanliness and comfort, was not adhered to, contributing to the deficiency.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were administered as ordered by the physician, affecting two residents. Resident #40, who was admitted with diagnoses including hypertensive heart disease, paraplegia, and type 2 diabetes mellitus with diabetic autonomic neuropathy, did not receive the prescribed Pregabalin 300 mg for neuropathic pain on multiple occasions. The medication was unavailable on 12/25/24 and 12/26/24, and the pharmacy was contacted, but the medication was not delivered until 12/27/24. This resulted in missed doses on both days, as confirmed by the Licensed Practical Nurse (LPN) and the Director of Nursing (DON). Resident #102, admitted with conditions such as esophagitis, type 2 diabetes mellitus with chronic kidney disease, also experienced a failure in medication administration. The resident was prescribed Pregabalin 200 mg three times a day for nerve pain, but the medication was not administered on several occasions between 01/03/25 and 01/13/25. The pharmacy was aware of the need for a new prescription, and the physician was notified, but the medication was not available until 01/13/25. Interviews with the pharmacist and nursing staff confirmed the lack of medication availability and the need for a new prescription. The facility's policies on administering medication and medication orders were not adhered to, as medications were not administered in a timely manner as prescribed. The policies required that drugs needing refills be reordered before the last dosage is administered to ensure availability, which was not followed in these cases. This deficiency was investigated under specific complaint numbers, indicating non-compliance with the facility's medication administration protocols.
Structural Deficiency Due to Vehicle Impact
Penalty
Summary
The facility failed to provide a safe environment for residents, staff, and the public due to a significant structural deficiency. A section of the exterior wall at the front of the facility was observed to have a hole approximately five feet wide by four feet high, which was covered with clean plastic. This opening extended into the interior section of the building, creating a potential safety hazard. The deficiency was initially caused by a vehicle accident around Thanksgiving, where a family member struck the facility with their vehicle. Interviews with the Maintenance Director and the Licensed Nursing Home Administrator revealed that the facility was initially waiting for the car owner's insurance to cover the damage. However, it was later discovered that the insurance would not cover the costs, and the facility's corporate office was involved in addressing the issue. Despite the insurance company's inspection on December 10, 2024, no quotes or estimates for repair had been completed by the time of the survey. The Maintenance Director expressed concerns about applying a hard surface to cover the hole, fearing it might cause further structural damage. The facility lacked a policy related to the need for repair, and the Public Adjustor confirmed that more substantial materials could be applied to prevent environmental elements from entering the facility.
RN Staffing Deficiency
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for eight consecutive hours, seven days a week, as required. This deficiency was identified during a review of staff punches for the week of August 4, 2024, through August 10, 2024, which revealed that no RN was on duty on Sunday, August 4, 2024. An interview with the Administrator on August 14, 2024, confirmed the absence of an RN on that date. The facility's policy, titled 'Staffing and Scheduling' and dated June 8, 2022, states that the facility will comply with Centers for Medicare and Medicaid Services (CMS) and state staffing requirements. This deficiency was investigated under Complaint Number OH00156691 and had the potential to affect all 78 residents in the facility.
Failure to Ensure Residents Were Free from Significant Medication Errors
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting two residents. Resident #23, who was cognitively intact and had diagnoses including malignant neoplasm of the rectum and chronic kidney disease, did not receive her prescribed capecitabine on two occasions in March 2024 because the medication was not available. Despite the nurse's communication with the pharmacy, there was no documentation that the physician was notified about the unavailability of the medication. The Director of Nursing confirmed that the medication should not have run out and verified that it was not given on the specified dates. Resident #34, who had diagnoses including paraplegia and type two diabetes, did not receive his prescribed fentanyl patch on one occasion in March 2024 due to the medication being unavailable. The resident confirmed that he did not receive the patch on the specified dates and only received it when it arrived from the pharmacy. There was no documentation that the physician was notified about the unavailability of the fentanyl patch. The Registered Nurse verified the documentation and stated that the resident would try to order medications from another pharmacy, which caused issues with reordering the medications.
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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 Dayton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Trinity Community | 3.6 mi | ★★★★★ | 0 | 0 |
| Beavercreek Health And Rehab | 3.8 mi | ★★★★★ | 7 | 0 |
| Village At The Greene | 4 mi | ★★★★★ | 4 | 0 |
| Widows Home Of Dayton | 5.5 mi | ★★★★★ | 4 | 0 |
| Kettering Heights Post Acute | 5.5 mi | ★★★★★ | 7 | 0 |
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