Below average — CMS composite of the measures below.
The next survey window likely opens around December 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 Bellbrook Health And Rehab during CMS and state inspections, most recent first.
A resident admitted with multiple comorbidities, including COPD and DM, was documented on admission as cognitively intact, needing assistance with ADLs, and having a coccyx pressure ulcer. The admitting LPN identified the ulcer but did not notify the physician or obtain wound treatment orders, instead applying barrier cream without an order. During discharge, an RN assisted with incontinence care but did not perform a full skin assessment. The resident’s representative reported not being informed of any treatment orders for the ulcer, which remained present upon transfer to another SNF. This occurred despite facility policy requiring physician-ordered wound treatments for newly admitted residents with pressure ulcers.
A resident with COPD, asthma, and atrial fibrillation was admitted with hospital orders to continue CPAP per home settings and a facility order for evening CPAP with 6–10 L O2 bleed-in. Documentation showed CPAP was given on two subsequent evenings, but there was no record of CPAP administration on the admission evening or of physician notification if it was unavailable. The admitting LPN reported the family left to retrieve the home CPAP and had not returned by shift end, while the evening LPN recalled providing oxygen but not whether CPAP was used. The resident’s family stated they brought in the CPAP that evening and informed staff, and the resident later reported CPAP had not been administered, indicating the ordered respiratory therapy was not provided or documented in accordance with facility policy.
A cognitively intact resident with multiple psychiatric and medical diagnoses reported to a provider that an LPN became angry, yelled, and used profanity toward them. This allegation of verbal abuse was documented in the medical record but was not entered into the facility’s SRI system, and the Administrator was not informed, so no timely reporting or investigation occurred as required by the facility’s abuse policy and federal timeframes.
Two residents experienced significant medication errors when staff administered drugs not in accordance with prescriber orders. One resident with multiple cardiovascular and neurologic conditions and moderate cognitive impairment reported severe chest pain; a CNA observed an LPN place a medication under the resident’s tongue, and hospital documentation reflected that the resident reported receiving sublingual nitroglycerin, despite no order for nitroglycerin on the MAR and the NP confirming no such order was given. Another resident with a history of cerebral infarction, hemiplegia, traumatic brain injury, and sepsis due to MRSA was documented in the incident log as having received the wrong IV antibiotic when a trainee nurse retrieved IV ceftriaxone from the medication refrigerator and started the infusion, after verification with a training nurse, instead of the ordered IV cefepime; the MAR showed an order only for cefepime, and the DON confirmed the wrong antibiotic had been administered.
A resident with multiple medical conditions and moderately impaired cognition refused a prepared dose of pregabalin, a controlled substance, after an LPN had removed the capsule from the narcotic drawer, signed it out, and emptied the contents into a medication cup. When the medication was refused, staff were unable to locate any designated waste solution for controlled substances, and the DON instructed the LPN to flush the pregabalin and other refused medications down the toilet. The LPN disposed of the controlled substance alone in an empty room without a second licensed nurse to witness the destruction, contrary to facility policy and Ohio regulatory requirements for controlled substance disposal and witnessing.
A resident with multiple cardiovascular and neurologic diagnoses, including cerebral infarction, paroxysmal atrial fibrillation, and hypertension, experienced chest pain and was given a sublingual nitroglycerin tablet before being sent to the hospital. An incident report, hospital H&P, SBAR note, and a CNA interview all confirmed that a sublingual medication was administered for chest pain, but there was no corresponding documentation in the resident’s progress notes or MAR. The DON confirmed that, apart from the incident report notation about medication given without an order, the facility lacked any medical record entry showing that sublingual nitroglycerin had been administered.
Surveyors found that the facility did not maintain its courtyard in good repair, despite residents having access to the area. A raised planter box was broken with exposed rusty nails, an inoperable portable heater was left on the concrete nearby, the surrounding wooden fence was loose and leaning into the courtyard and held up by a bag of sand, and a wooden picnic table had peeling paint and deteriorating wood. These conditions were confirmed with the Administrator and were inconsistent with the facility’s Homelike Environment policy requiring a clean, sanitary, and orderly environment.
Unsecured and improperly stored medications were found on a medication cart and in a resident’s room. An LPN left the 300-hall med cart unlocked and out of sight, and the cart contained loose pills, a sticky substance, and contaminated medication bottles. In another instance, a resident with dementia and impaired cognition had a medication cup with six pills left on the bedside table within reach.
Frozen foods were not kept at the required temperature after the walk-in freezer stopped working and food was left inside with the door closed. The DM observed the freezer at 28 degrees Fahrenheit with hamburger patties, french fries, and vegetables in various states of thawing, and confirmed the food was no longer frozen. The facility also identified 11 residents with NPO orders who did not receive food from the kitchen.
A resident with epilepsy and moderately impaired cognition experienced a seizure lasting several minutes, during which the resident had difficulty breathing and was given scheduled Keppra and oxygen by an LPN, despite no existing oxygen order and the resident not typically requiring oxygen. The event was not documented in the medical record, and neither the provider nor the resident’s representative was notified at the time, even though the care plan and the facility’s acute condition change protocol required reporting seizure activity and contacting the physician. Another LPN involved confirmed that no provider notification occurred, and the NP later stated she was not informed of the seizure until days afterward.
A resident with stroke, dementia, type 2 DM, depression, anxiety, and polyneuropathy, who was cognitively impaired and dependent on staff for ADLs, did not receive adequate nail care as outlined in the care plan and facility ADL policy. Surveyors observed that the resident’s fingernails were overgrown and encrusted with a dark brown substance, and the resident reported staff had not offered to clean or trim them. A CNA acknowledged the nails were long and dirty and cited limitations on CNAs cutting the nails of diabetic residents, while an LPN stated CNAs were expected to clean and trim nails during bathing and that nurses or a podiatrist were responsible for trimming nails of residents with diabetes. Later observation showed the nails had been cleaned but remained uncut, demonstrating a failure to ensure complete nail care for this dependent resident.
A resident with acute respiratory failure, tracheostomy status, and multiple peripheral IV lines did not receive ordered wound vac dressing changes or documented IV site care during a short stay. The abdominal wound vac was applied once, but no subsequent dressing changes were recorded on the ordered schedule, and no skin or wound assessments were documented from admission through discharge. Despite IV pump alarms, painful IV access, and erythema under a transparent dressing that led to removal of one line and continuation of IV therapy through another site, there was no documentation of IV site care or monitoring. The DON confirmed the absence of skin/wound assessments, wound vac changes, and IV site care for this resident throughout the stay.
A resident with impaired cognition, hemiplegia, and dependence on staff for ADLs had a care plan and fall investigation specifying bilateral fall mats at the bedside and a call light within reach while in bed. Surveyors repeatedly observed the resident in bed without required fall mats in place—sometimes with no mats on the floor, sometimes with only one mat, and at times with a mat leaning against the wall. The resident also reported needing help with briefs while the call light lay on the floor out of reach, which staff confirmed. These observations showed that the facility did not consistently implement the resident’s fall-prevention interventions or ensure access to the call system as required by facility policy.
Lack of Privacy for Resident Telephone Calls: A resident with CVA-related hemiplegia, anxiety, PTSD, and depression was observed making personal calls at the nursing station desk while other residents were nearby or directly next to her. Staff stated the 300-hall cordless phone did not work, and an LPN handed the resident the desk phone because it was the only phone available. The resident said she was not offered a private area or private phone for personal calls and preferred privacy.
Missed Quarterly Care Conferences for Three Residents: The facility failed to hold required quarterly care conferences with the IDT and the resident and/or resident representative for three residents. One resident with severe cognitive impairment and complex medical diagnoses had only one care conference during the year, while another cognitively intact resident had no conference for one quarter and a third resident with COPD, aortic stenosis, and AFib had no conference for one quarter. The MDS Coordinator confirmed the missing conferences, and one resident could not recall attending any care conferences.
Inaccurate medical record and active fall mat order not reflected in care. A resident’s chart lacked progress notes describing a fall incident, even though later IDT documentation referenced the event and noted poor safety awareness and transfer limitations. The TAR showed the fall mat was documented as in place on all shifts, but observations found no mat at the bedside and an RN confirmed it was not there. The DON and RCN stated the intervention had been removed after an IDT meeting, but the physician order remained active.
A resident with multiple medical conditions was discharged without a proper discharge plan, summary, or physician orders, and was sent home without insulin or a primary care physician in place. The facility also failed to notify the local ombudsman office of the discharge, as required, due to sending information to an incorrect fax number.
A resident with stage four pressure ulcers was not repositioned as required by their care plan, leading to a deficiency finding. Despite being at high risk for pressure ulcers, the resident was left on their left side for over two hours without repositioning. Staff interviews revealed lapses in care provision, with some staff not present or not providing care during their shifts. The facility's policy on pressure injury prevention was not followed, resulting in non-compliance.
A facility failed to follow enhanced barrier precautions for a resident with anoxic brain damage and stage four pressure ulcers. Staff entered the resident's room with a treatment cart and only wore gloves, neglecting additional PPE. A nurse aide, after touching soiled items, retrieved supplies from the cart without changing gloves, contaminating the supplies. Interviews confirmed the cart should not have been in the room and proper PPE was not used.
The facility failed to maintain exterior windows in resident rooms, affecting seven residents. Observations revealed plastic covering windows in two rooms to prevent cold air, and five rooms had missing screens. Interviews confirmed these issues, with one resident reporting a squirrel entering her room due to the lack of a screen. The Maintenance Director acknowledged the problems and lack of documentation for repairs.
Failure to Notify Physician and Obtain Orders for Existing Pressure Ulcer on Admission
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician of an existing pressure ulcer upon admission and to obtain treatment orders for that ulcer. A resident admitted on 04/17/26 with diagnoses including COPD, diabetes mellitus, and atrial fibrillation was documented on the admission Data Collection evaluation as cognitively intact and needing staff assistance with bed mobility, transfers, toilet hygiene, and bathing. That same evaluation documented a pressure ulcer on the coccyx measuring 5.0 cm in length by 1.0 cm in width with less than 0.1 cm depth, present on admission. The only physician order on 04/17/26 related to skin/pressure management was for a low air loss mattress, and from 04/17/26 through discharge on 04/20/26 there was no documentation that the physician was notified of the pressure ulcer or that specific wound treatment orders were obtained. The admitting LPN confirmed in interview that she identified the coccyx pressure ulcer on admission, did not notify the physician, and independently applied barrier cream without obtaining treatment orders. The RN who assisted with the resident’s discharge reported helping a CNA with incontinence care and turning the resident but stated she did not complete a skin assessment prior to discharge and did not observe skin breakdown at that time. The resident’s representative reported that the resident had been admitted with a pressure ulcer acquired in the hospital, that she was not informed of any treatment orders for the ulcer while the resident was at the facility, and that the ulcer was still present when the resident was admitted to another skilled nursing facility on 04/20/26. Facility policy required that newly admitted residents be examined for existing pressure ulcers and that the physician order pertinent wound treatments, including pressure reduction surfaces, wound cleansing, debridement, dressings, and topical agents, which did not occur in this case.
Failure to Administer Ordered CPAP Therapy on Admission
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s continuous positive airway pressure (CPAP) therapy was administered according to physician orders on the day of admission. The resident, who was cognitively intact and had diagnoses including chronic obstructive pulmonary disease, asthma, and atrial fibrillation, was admitted with hospital discharge orders to continue CPAP per home settings. Facility physician orders dated the day after admission directed application of the home CPAP with 6–10 liters of oxygen bleed-in every evening shift. Review of the Treatment Administration Record showed CPAP was documented as applied on the two evenings following admission, but there was no documentation that CPAP was administered on the admission date, despite the discharge orders specifying continuation of CPAP. Interviews further clarified the events leading to the deficiency. The admitting LPN stated the resident had an order for home CPAP every evening and that the family went home to retrieve the CPAP machine but had not returned by the end of her shift. The evening-shift LPN confirmed the resident received oxygen that evening but could not recall whether the CPAP machine had been brought in or used. In contrast, the resident’s representative reported that the family did bring the CPAP machine to the facility that evening and informed both the nurse and the Respiratory Therapist, and that the resident later reported staff had not administered the CPAP. The Regional Nurse confirmed there was no documentation in the medical record that CPAP was administered as ordered on the admission date or that the physician was notified if CPAP was not available, despite facility policy requiring review of physician orders and appropriate CPAP/BiPAP support.
Failure to Timely Report Allegation of Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of verbal abuse and initiate an investigation in accordance with its abuse reporting policy and federal requirements. Resident #23, admitted on 02/02/26 with diagnoses including bipolar disorder (current episode manic without psychotic features, moderate), anxiety disorder, hypothyroidism, mixed hyperlipidemia, major depressive disorder (single episode, severe, without psychotic features), and hypertension, was documented as cognitively intact on the admission MDS. The MDS also showed the resident required supervision for toileting, bathing, dressing, and transfers, setup assistance for oral and personal hygiene, and was independent with eating and bed mobility. On 02/16/26, a provider visit note signed by Former Nurse Practitioner #175 documented that Resident #23 reported an incident in which a staff member, identified as LPN #94, became angry, yelled, and used profanity toward the resident. Review of the facility’s electronic Self-Reported Incidents (SRI) system from 02/16/26 to 03/11/26 showed no alleged incidents involving this resident had been entered. During an interview on 03/11/26, the Administrator stated she had not been informed of any abuse allegation involving LPN #94 and Resident #23 and indicated she would have reported and investigated the allegation if she had been made aware. Review of the facility’s Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, revised 04/2021, showed the facility was required to investigate and report any allegations within federally required timeframes; this did not occur for the allegation involving Resident #23.
Significant Medication Errors Involving Unauthorized Nitroglycerin and Wrong IV Antibiotic
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, specifically involving two residents who received medications not in accordance with prescriber orders. One resident with diagnoses including cerebral infarction, paroxysmal atrial fibrillation, hypertensive urgency, adult failure to thrive, and essential hypertension, and who had moderately impaired cognition, reported severe chest pain rated 9/10 one morning. Documentation in the resident’s progress and SBAR note showed the resident was sent to the emergency department after the onset of chest pain and that the primary care clinician (a nurse practitioner) was notified, but there was no documentation of any medication administered in response to the chest pain in the medical record. An incident report prepared by the DON documented that the resident complained of chest pain, vital signs were taken, the NP was called, and that medication was given to the resident without an order before the resident was sent to the ER. A hospital history and physical note recorded that the patient stated they had been given a dose of sublingual nitroglycerin prior to coming to the emergency department. The NP later stated that, to their knowledge, the resident was given sublingual nitroglycerin without an order and that facility staff called after the medication had already been administered, asking for an order to be placed retroactively, which the NP did not do. The DON reported being aware that sublingual nitroglycerin had been administered without an order and that no nurse on duty would admit to giving the medication, while a CNA reported witnessing an LPN place a medication under the resident’s tongue in response to the chest pain. Review of the resident’s physician orders and MAR for the month showed no order for sublingual nitroglycerin. The second resident involved had diagnoses including cerebral infarction, hemiplegia and hemiparesis following cerebral infarction, diffuse traumatic brain injury with loss of consciousness, essential hypertension, anxiety, and a more recent diagnosis of sepsis due to MRSA. The facility’s Incident and Accident Log documented a medication error for this resident on one date, indicating that the wrong antibiotic had been administered. An incident report showed that the resident was given IV ceftriaxone instead of the ordered IV cefepime, and that the incorrect antibiotic infusion ran for approximately five to ten minutes before being stopped. The report indicated that a trainee nurse obtained the wrong antibiotic from the medication refrigerator and started the infusion after verifying the resident’s name, medication, and dose with another nurse who was training them. Review of the MAR confirmed an active order for IV cefepime and no order for IV ceftriaxone. The DON confirmed that a medication error occurred when the wrong antibiotic was administered. The facility’s policy on administering medications required that medications be administered in accordance with prescriber orders, which was not followed in these instances.
Improper Disposal and Lack of Witnessing for Controlled Substance Waste
Penalty
Summary
Surveyors identified a deficiency related to improper disposal of a controlled substance for one resident with moderately impaired cognition and multiple medical diagnoses, including cerebral infarction, paroxysmal atrial fibrillation, hypertensive urgency, adult failure to thrive, and essential hypertension. During a morning medication pass, an LPN removed a 150 mg pregabalin capsule from a locked medication cart drawer, signed it out in the narcotic tracking binder, opened the capsule, and poured the contents into a medication cup for administration. The resident subsequently refused the pregabalin along with all other morning medications offered. After the refusal, surveyors observed that the facility had no waste/disposal solution available to safely discard pregabalin powder or other controlled substances, and staff were unable to locate any such solution. The DON stated that a regional director would need to obtain a disposal solution from another facility and, in the meantime, instructed the LPN to dispose of the pregabalin and other refused medications by flushing them down the toilet. The LPN then entered an empty, unassigned room and flushed the controlled substance without another staff member present to witness the disposal. The DON later confirmed that disposal of controlled substances should be witnessed by another licensed nurse, and facility policy and the cited Ohio Administrative Code require controlled substances to be disposed of in accordance with applicable regulations and with appropriate witnessing by licensed nursing staff.
Failure to Accurately Document Administration of Sublingual Nitroglycerin
Penalty
Summary
The facility failed to maintain an accurate and adequately comprehensive medical record for one resident when documentation did not reflect the administration of sublingual nitroglycerin given for chest pain. The resident, who had diagnoses including cerebral infarction, paroxysmal atrial fibrillation, hypertensive urgency, adult failure to thrive, and essential hypertension, was assessed as having moderately impaired cognition on the most recent MDS. On the date in question, an incident report, an outside hospital history and physical, and an SBAR nursing communication note all indicated that the resident was administered a sublingual nitroglycerin tablet at the facility in response to complaints of chest pain prior to transfer by ambulance. Despite these records and a CNA’s interview confirming they witnessed a medication being placed under the resident’s tongue for chest pain, the resident’s facility medical record did not contain any progress note documenting the administration of a sublingual medication or nitroglycerin on that date. Additionally, the resident’s MAR for the month showed no entry indicating that sublingual nitroglycerin had been administered. The DON confirmed that, aside from the notation on the incident report referencing medication given without an order, there was no facility-produced documentation identifying that the resident received sublingual nitroglycerin.
Failure to Maintain Courtyard Area in Safe and Sanitary Condition
Penalty
Summary
The facility failed to ensure that outdoor areas were maintained in good repair and in a clean, sanitary, and orderly condition, as required by its Homelike Environment policy. Observation of the outdoor courtyard showed a square raised planter box filled with soil that had a broken corner coming apart, exposing rusty nails. A small inoperable portable heater was left on the concrete next to the planter box, and the wooden fence enclosing the courtyard was loose, falling toward the courtyard, and propped up by a bag of sand. Additionally, a wooden picnic table in the courtyard was covered in peeling paint and the wood appeared to be deteriorating. During an interview and observation with the Administrator, these conditions in the courtyard were confirmed, including the broken planter box with exposed rusty nails, the portable heater in the courtyard, and the loose, leaning wooden fence. The Administrator also confirmed that residents have access to this courtyard area. The deficiency was cited as non-compliance under Complaint Numbers 2566940 and 2581568 and had the potential to affect all 34 residents residing in the facility.
Unsecured and Improperly Stored Medications
Penalty
Summary
The facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional principles. During observation of the 300-hall medication cart, an LPN walked away from the cart and rounded the corner while the cart was left unlocked and out of sight. A later observation of the same cart found five white pills out of packaging in the second drawer, a pink sticky substance in the third drawer with eight medication bottles contaminated by the substance, two loose pills in the third drawer, and one capsule out of packaging in the bottom drawer. The deficiency also involved unattended medication in a resident room. Resident #11 was admitted on 08/23/22 and had a diagnosis of dementia without behaviors; the quarterly MDS assessment noted impaired cognition. During observation in the resident’s room, a medication cup containing six pills was found on the bedside table within the resident’s reach. The RCN confirmed the medication had been left unattended in the room earlier that morning and removed the pills.
Frozen Foods Not Maintained at Safe Temperature
Penalty
Summary
Frozen foods were not maintained at appropriate temperatures when the facility’s walk-in freezer stopped working the previous afternoon and food was left inside with the door closed in an attempt to keep it cold. During observation, the freezer temperature was 28 degrees Fahrenheit, and food stored in boxes on the shelves, including hamburger patties, bulk french fries, and vegetables, was found in various states of thawing. The Dietary Manager confirmed the food in the freezer was no longer frozen. The facility identified 11 residents who did not receive food from the kitchen because they had physician orders to be nothing by mouth. Facility policy stated frozen foods are to be maintained frozen solid.
Failure to Notify Provider and Representative After Seizure and Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify the provider and resident representative of a resident’s change in condition following a seizure event, and failure to document the event and related care. Resident #9, admitted on 10/19/22 with diagnoses including epilepsy and moderately impaired cognition per the MDS, had a care plan revised on 10/17/25 that directed staff to monitor and report any seizure activity and to report abnormal vital signs to the physician. Despite this, review of progress notes from 01/07/25 to 01/14/25 showed no documentation of a seizure or any notification to the provider or resident representative. The DON confirmed there was no documentation of the seizure that occurred on 01/12/26 and no documentation of notification to the provider or resident representative, and also confirmed there was no order for oxygen in the resident’s record. Staff interviews further detailed the unreported and undocumented change in condition. One LPN stated that Resident #9 had a seizure on the night of 01/12/26 lasting about five minutes, during which the resident had difficulty breathing while lying on his back; the LPN administered scheduled Keppra and applied oxygen at 2.5 liters, even though the resident did not have an oxygen order and did not normally require oxygen. The LPN reported believing another LPN had obtained an oxygen order from the provider while he was in the room, but the second LPN later confirmed he did not notify the provider and did not speak to the provider about oxygen. The NP confirmed she was not notified of the seizure until 01/14/26 and stated that, had she been informed at the time, labs would have been ordered. Review of the facility’s “Acute Condition Changes Clinical Protocol” dated 03/2018 showed that nursing staff are required to contact the physician based on the urgency of the situation and discuss possible causes and needed diagnostic tests, which did not occur in this case.
Failure to Provide Adequate Nail Care for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate assistance with personal hygiene and nail care to a resident who was dependent on staff for activities of daily living. The resident was admitted with multiple diagnoses including stroke, dementia without behaviors, type 2 diabetes mellitus, depression, anxiety, and polyneuropathy, and was documented on a quarterly MDS as cognitively impaired and dependent on staff for personal hygiene and toileting. The resident’s care plan identified a physical functioning deficit and included an intervention for nail care as needed. During an observation and interview, the resident’s fingernails were noted to extend approximately one eighth of an inch beyond the fingertips and were encrusted with a dark brown substance. The resident reported that staff had not offered to clean or trim his nails and stated he would like assistance with nail care. Further observations and staff interviews confirmed the lack of appropriate nail care. A CNA acknowledged that the resident’s fingernails were long and dirty and stated that another CNA had said she would take care of the nails. The CNA indicated she would clean the nails and notify a nurse that the resident’s nails needed to be cut, explaining that CNAs were not permitted to cut the nails of residents with diabetes. An LPN stated that the expectation was for CNAs to clean and trim residents’ nails during showers or bed baths, and that for residents with diabetes, it was the responsibility of a nurse or podiatrist to ensure nails were trimmed. A subsequent observation showed the resident’s fingernails were clean but still uncut. The facility’s ADL policy stated that residents unable to carry out ADLs independently would receive appropriate support and assistance with hygiene, including grooming, but this was not followed for this resident’s nail care.
Failure to Provide Ordered Wound Vac Care and IV Site Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered treatment and adequate assessment for a resident with complex medical needs, including a wound vac and multiple IV lines. The resident was admitted with diagnoses of acute respiratory failure with hypoxia, anxiety disorder, tracheostomy status, and depression, and had moderately impaired cognition and dependence on staff for toileting and bathing. From admission through discharge, there were no wound or skin assessments documented, despite the presence of an abdominal wound vac ordered at 100 mmHg suction with dressing changes scheduled for Monday, Wednesday, and Friday on dayshift. The record shows the wound vac was applied on one date, but there is no documentation of any subsequent wound vac dressing changes on the ordered days. The resident also had multiple peripheral IV lines, including sites in the left wrist, left shoulder, and right forearm. Progress notes describe IV pump alarms and attempts to use different peripheral lines, including removal of one access due to resident-reported pain and observed erythema beneath the transparent dressing, with notification of the NP and continuation of IV medications via another access. However, from admission through discharge, the progress notes and TAR contain no documentation of IV site care or monitoring of the access sites. In interviews, the DON confirmed that no skin or wound assessments were completed, no wound vac changes were performed after the initial application, and no IV site care was documented for this resident during the stay.
Failure to Implement Fall-Prevention Interventions and Ensure Call Light Access
Penalty
Summary
The facility failed to ensure that fall-prevention interventions and call light access were consistently in place for a resident with a known history of falls and significant functional impairments. The resident, admitted with diagnoses including epilepsy, cerebral infarction, and hemiplegia/hemiparesis of the left non-dominant side, had a Minimum Data Set showing moderately impaired cognition and dependence on staff for toileting, bathing, and personal hygiene. The care plan, initiated due to fall risk related to impaired mobility, required bilateral fall mats on each side of the bed, the call light within reach at all times when in bed, education and reminders to use the call light before transfers and for toileting needs, personal items within reach, and a sign at eye level reminding the resident to use the call light. A prior fall investigation also identified bilateral fall mats as an intervention. Despite these documented interventions and policies, multiple observations showed that the fall-prevention measures were not implemented as planned. On several occasions, the resident was observed lying in bed without fall mats on the floor, with the mat either leaning against the wall or present on only one side of the bed. At one point, the resident reported needing help with adult briefs while the call light was on the floor and not within reach, which was confirmed by a CNA. Subsequent observations continued to show inconsistent placement of fall mats, with only one mat on the right side or the mat again leaning against the wall instead of being on the floor beside the bed. These findings occurred in the context of facility policies requiring a resident-centered fall prevention plan and provision of a means for residents to call staff from bed and other locations.
Lack of Privacy for Resident Telephone Calls
Penalty
Summary
The facility failed to provide privacy for telephone calls for one resident reviewed for telephone use. Resident #50 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, anxiety disorder, post-traumatic stress disorder, and depression. The admission data collection form documented the resident as alert and oriented times four. During observation, Resident #50 was seen at the 300-Hall nursing station using the desk telephone for a personal call while multiple residents were in the hallway, and later was again observed at the nursing station desk talking on the telephone with another resident sitting directly next to her. Staff interviews confirmed the lack of private telephone access on the 300-Hall. The BOM stated residents were usually given the cordless telephone from the front desk, but Resident #50 was using the regular desk telephone. An LPN stated Resident #50 asked to call her father and was handed the desk telephone, adding that it was the only telephone she had to use and there was no private telephone. Resident #50 stated she was not offered any private area or private telephone for personal calls and preferred a private area. An RN and the Maintenance Director both stated the cordless telephone at the main nursing station was used for residents to make private calls, but it did not work on the 300-Hall. The resident admission packet stated residents have the right to reasonable access to a telephone and a place where calls can be made without being overheard.
Missed Quarterly Care Conferences for Three Residents
Penalty
Summary
The facility failed to ensure resident care conferences were held quarterly with the interdisciplinary team and the resident and/or resident representative for three reviewed residents. Resident #34, admitted on 04/01/14 with diagnoses including diffuse traumatic brain injury, disease of the digestive system, diabetes mellitus, dysphagia, and major depressive disorder, had severe cognitive impairment on the MDS 3.0 assessment. The record showed only one care conference in 2025, held on 07/17/25, with no care conferences in the first, second, or fourth quarters of 2025. The MDS Coordinator confirmed that only one care conference occurred for that resident during the year. Resident #9, admitted on 10/19/22 with diagnoses including epilepsy, cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, and major depressive disorder, was cognitively intact on the MDS 3.0 assessment. The record showed no third quarter 2025 care conference, and the resident stated he could not remember any care conferences he attended or was asked to attend. Resident #8, admitted on 11/03/24 with diagnoses including COPD, nonrheumatic aortic stenosis, and chronic atrial fibrillation, had moderately impaired cognition on the MDS 3.0 assessment. The record showed no first quarter 2025 care conference. The facility admission packet stated residents have the right to participate in the development and implementation of their person-centered plan of care, and the policy stated residents and their representatives are encouraged to participate in assessment and care plan development and implementation.
Inaccurate medical record and active fall mat order not reflected in care
Penalty
Summary
The facility failed to maintain an accurate medical record for one resident. The record for the resident showed an admission date of 05/09/25 and included a progress note dated 12/08/25 stating the interdisciplinary team met to discuss an incident that occurred on 11/10/25. That note indicated the team determined the resident had poor safety awareness and was unaware of transfer limitations, but there were no progress notes in the chart on or around 11/10/25 describing the incident itself. Later review of the active physician orders showed an order dated 11/12/25 for a fall mat to be placed to the left side of the resident’s bed when in bed, with placement to be verified every day on each shift. Review of the TAR for November 2025, December 2025, and January 2026 showed nursing staff documented the fall mat was in place at bedside for all shifts, and an RN signed the record confirming placement. However, observations on 01/12/26 and again on 01/14/26 showed no fall mat on either side of the resident’s bed while the resident was lying in bed. During interview, the RN confirmed there was no fall mat at the bedside and then obtained one and placed it there. The DON later stated the IDT met on 12/15/25 and determined the fall mat was no longer an appropriate intervention, and the order should have been discontinued on that date. The RCN clarified that the incident on 11/10/25 was a fall and confirmed the fall mat intervention had been removed after the IDT meeting, but the order remained active.
Failure to Provide Proper Discharge Planning and Ombudsman Notification
Penalty
Summary
The facility failed to provide a proper discharge for a resident, as evidenced by the lack of a discharge plan, discharge summary, and appropriate physician orders for discharge. The resident, who had diagnoses including orthostatic hypotension, diabetes mellitus, dehydration, dysphagia, and anxiety disorder, was cognitively intact but dependent on staff for medication administration and required assistance with activities of daily living. Despite the resident expressing discomfort and uncertainty about self-administering insulin and not feeling ready to go home, the discharge proceeded without ensuring a primary care physician was in place or a follow-up appointment scheduled. The discharge documentation was incomplete, with only the social services section partially filled out and no signatures or summaries from nursing, dietary, activities, or rehabilitation services. The resident was discharged to an independent living apartment, not an assisted living facility as some staff believed. Upon discharge, the resident did not have insulin or a primary care physician, and home health staff had to intervene to secure necessary medication and assist in finding a physician. The facility's own policy required a discharge summary and post-discharge plan to be developed and filed in the resident's medical record, but this was not done. Interviews with staff confirmed the absence of a discharge summary, discharge plan, and proper coordination for the resident's ongoing care needs. Additionally, the facility failed to properly notify the local ombudsman office of the resident's discharge. Monthly discharge lists were faxed to an incorrect number, and there was no documented evidence that the ombudsman received any notifications of discharges over a six-month period. The ombudsman confirmed they had not received any such notifications, and the facility administrator acknowledged the error and lack of documentation.
Failure to Reposition High-Risk Resident
Penalty
Summary
The facility failed to provide timely repositioning and turning for a resident with existing stage four pressure ulcers on the left elbow and sacrum. The resident, who was at high risk for developing pressure ulcers due to impaired mobility, was observed lying on their left side for over two hours without being repositioned. The care plan for the resident included interventions such as turning and repositioning every one to two hours, using a low air loss mattress, and conducting weekly wound assessments. However, these interventions were not consistently followed, as evidenced by the lack of repositioning observed during the survey. Interviews with facility staff revealed that the resident was not repositioned from 5:00 A.M. until 11:42 A.M. on the day of the observation. The staff responsible for the resident's care during this period either did not provide care or were not present due to various reasons, such as being called in late or leaving early. The facility's policy on the prevention of pressure injuries emphasized the importance of following the care plan for repositioning, which was not adhered to in this case. This deficiency was investigated under a specific complaint number, indicating non-compliance with the facility's pressure ulcer prevention protocols.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to enhanced barrier precautions for a resident who was re-admitted with anoxic brain damage and stage four pressure ulcers on the left elbow and sacrum. During an observation, a registered nurse and a state-tested nurse aide entered the resident's room to perform incontinence care, repositioning, wound care, and check the urinary catheter. The staff brought the wound treatment cart into the room and only wore gloves, neglecting to use additional personal protective equipment as required by the facility's enhanced barrier precautions policy. The state-tested nurse aide, after touching the resident's linens and incontinent brief, was instructed to retrieve a four-by-four dressing from the treatment cart. The aide did not remove her soiled gloves, perform hand hygiene, or don new gloves before searching through the treatment cart's drawers, thereby contaminating the supplies. Interviews with the Director of Nursing and the registered nurse confirmed that the treatment cart should not have been taken into the room and that the aide should not have reached into the cart with dirty gloves. The facility's policy mandates the use of gowns and gloves during high-contact care activities, which was not followed in this instance.
Failure to Maintain Exterior Windows in Resident Rooms
Penalty
Summary
The facility failed to ensure that exterior windows in resident rooms were properly maintained, affecting seven residents. Observations revealed that plastic was covering the windows and blinds in two residents' rooms, preventing the blinds from being opened without damaging the plastic. This plastic was applied to mitigate cold air entering the rooms due to old windows. Additionally, five other residents' rooms were found to have missing screens in their exterior windows, which had been an issue for a long time according to the Maintenance Director. Interviews with the affected residents confirmed the presence of plastic over the windows and the absence of screens, with one resident even reporting that a squirrel had entered her room due to the lack of a screen. The Maintenance Director confirmed the issues with the windows and the absence of screens, stating that there was no documentation of any window repairs, invoices, or assessments for the affected rooms. The plastic coverings were applied in December 2023 or January 2024 to address the cold air problem. The deficiency was identified during a survey conducted on 04/26/24, and it was noted that the facility had not taken adequate steps to maintain the windows, resulting in discomfort and potential safety hazards for the residents.
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 535 citations issued within 25 miles in the last 12 months — including the 3 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 Bellbrook
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oak Creek Terrace Inc | 2.2 mi | ★★★★★ | 3 | 0 |
| St Leonard Hcc | 2.2 mi | ★★★★★ | 2 | 0 |
| Bethany Village | 3.1 mi | ★★★★★ | 0 | 0 |
| Village At The Greene | 4 mi | ★★★★★ | 4 | 0 |
| Trinity Community | 4.4 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.