Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Blue Ash Health & Rehab during CMS and state inspections, most recent first.
The facility failed to maintain consistent and adequate hot water in resident areas, resulting in multiple residents reporting that water in their rooms, including for bathing, remained cold or only lukewarm for an extended period. On survey, the Maintenance Director documented highly variable water temperatures in resident bathrooms, from very low to excessively high, and a shower room with very hot water, while a laundry sink had no water pressure and was leaking. In the boiler rooms, water lines were difficult to trace, thermometers on some lines were not functioning, and tagged valves for kitchen hot and cold water were noted as not working. The Maintenance Director, recently hired, had not engaged a plumber, was unsure of the configuration of the water lines, and confirmed the non-functioning equipment and valves, contrary to the facility’s policy to provide a safe and comfortable environment.
Several residents with complex medical conditions were left in rooms without adequate heat for months, with room temperatures below policy standards. Residents were observed shivering, seeking warmth in hallways, and requesting assistance, but were not offered alternative accommodations. Facility staff confirmed the ongoing heating issue and lack of documentation regarding resident relocation.
A resident with impaired cognition and multiple medical conditions alleged that an LPN grabbed her arms during care, resulting in discoloration. The facility's investigation was limited to statements from the LPN and the resident, with no additional witness interviews or documentation collected. The investigation was closed without a thorough review, contrary to facility policy.
A resident with multiple medical conditions was found smoking unsupervised inside the facility, despite a care plan and facility policy requiring supervision and restricted access to smoking materials. Staff confirmed that smoking was only allowed in a designated area under supervision, and that smoking items should be stored securely. The resident was able to obtain smoking materials and smoke outside of scheduled times, indicating a failure to provide adequate supervision and a safe environment.
A resident with complex medical and behavioral health needs was not provided with information or assistance to apply for long-term Medicaid benefits after her skilled care Medicaid coverage ended. Despite facility policy requiring such assistance, staff confirmed that the resident was not offered help with the Medicaid application process.
A resident with chronic respiratory failure and other serious health conditions was discharged without home health or ongoing oxygen services, and the facility did not confirm a safe discharge location. Staff interviews revealed the resident was not given the opportunity to appeal a Medicaid decision, was told to leave on short notice, and was only provided a four-hour oxygen tank. After discharge, the resident required hospitalization and became homeless. The Ombudsman and Medical Director confirmed that proper arrangements for a safe discharge were not made.
A resident with complex medical and psychiatric conditions was discharged without a written notice, proper documentation, or notification to the Ombudsman. The resident was told to leave within 12 hours due to Medicaid payment issues, was not informed of appeal rights, and was discharged without home health or oxygen services arranged. Facility staff and the Medical Director confirmed that required discharge procedures and notifications were not followed.
Surveyors observed a dirty kitchen floor with food crumbs, cracks, and smeared dirt, a full trash can without a lid, a hair net on the floor, and a pile of soiled linens with an unknown black substance under the sink near the prep table. Staff confirmed these conditions and reported a major spillage incident. Facility policy required a clean and sanitary food preparation area, but these standards were not met, potentially affecting all residents receiving food from the kitchen.
A resident with severe cognitive impairment and a physician-ordered pureed diet with thickened liquids was given corn bread by an LPN who did not verify the resident's dietary restrictions. The resident choked after consuming the corn bread and required the Heimlich maneuver by two nurses. Facility policy required staff to check diet orders before serving food, but this was not followed, resulting in the deficiency.
A resident with cognitive impairment and multiple medical conditions was found in bed without a call light or personal items within reach, and no floor mat was present, despite care plan interventions requiring these fall prevention measures. Facility staff confirmed the lack of required safety interventions during observation.
The facility failed to administer oxygen as ordered by a physician for three residents, leading to deficiencies in oxygen administration. A resident with COPD was observed with outdated oxygen equipment and no signage indicating oxygen use. Another resident with COPD had undated equipment and lacked a physician's order for changing it. A third resident with congestive heart failure was receiving oxygen without a physician's order, using outdated equipment, and without proper signage. Interviews confirmed these deficiencies, and the facility's policy required physician orders and signage for oxygen use.
A resident with severe cognitive impairment was discharged from the facility without a physician's order or proper documentation. The responsible party was informed via phone and text, but a written notice was sent after the discharge. The facility's policy required documentation and a physician's order, which were not provided.
A resident with severe cognitive impairment was discharged from the facility without prior written notice to the resident or their representative. The facility sent a 30-day discharge notice after the discharge had occurred, contrary to their policy requiring advance notice. The responsible party was informed of the discharge through informal communication rather than formal written notice.
The facility did not have an RN on duty for eight consecutive hours on two days, as required. A review of the staffing schedule showed no RN was scheduled on those days, which was confirmed by the President of Operations. This affected the facility's 52 residents and was investigated under a complaint.
The facility failed to maintain Medicaid coverage for two residents, one with cognitive impairments and another requiring extensive ADL assistance. Both had Medicaid pending as their primary payor source, and an interview confirmed the facility did not provide necessary information to maintain coverage, resulting in a lapse.
A facility failed to ensure staff followed PPE guidelines for a resident on EBP due to a catheter. The resident, with conditions including neuromuscular dysfunction of the bladder and paraplegia, required substantial assistance with ADLs. During catheter care, a CNA did not wear a gown, contrary to facility policy requiring gowns and gloves for high-contact care activities. The CNA confirmed the oversight.
A resident with decreased mobility and medication side effects was not adequately monitored for constipation, resulting in a large fecal impaction and hospitalization. The facility lacked a policy for constipation management and failed to generate clinical alerts for missed bowel movements, leading to no PRN orders or provider notifications.
A resident with an indwelling catheter was found with a urine collection bag lying on the floor, contrary to the facility's catheter care policy. The resident, who required maximum assistance with toileting, reported that the bag frequently fell when the bed position was changed. A State tested Nurse Aide confirmed the improper storage, acknowledging that the bag should have been clipped to the bed.
Failure to Maintain Consistent and Adequate Hot Water in Resident Areas
Penalty
Summary
The deficiency involves the facility’s failure to provide hot water in resident areas consistent with resident preferences and its own policy for a safe, clean, and comfortable environment. Multiple residents reported that the water in their rooms did not get hot, including during bathing, and that this had been an ongoing issue for months. On the day of survey, the Maintenance Director measured widely variable water temperatures in resident bathrooms, ranging from as low as approximately 61°F to as high as approximately 136°F, with several rooms having only cold or lukewarm water and others having very hot water. One shower room had water at about 121°F, and the laundry room sink had no water pressure and was leaking, preventing measurement of water temperature. Further observations in the boiler rooms showed that the water lines were very difficult to trace, and there were non-functioning thermometers attached to some water lines. Several orange tags were found on the lines, including tags indicating that the cold supply to the kitchen valve and the kitchen hot water valve were not working. The Maintenance Director, who had been employed for three weeks, stated he had never had a plumber come to the facility, was unsure which lines were which, and confirmed the non-functioning thermometers and tagged, non-working valves. Residents and staff interviews consistently described long-standing problems with cold water on one side of the building and in specific rooms, demonstrating that the facility did not ensure reliable hot water service in resident areas as required by its safe and homelike environment policy.
Failure to Maintain Safe Room Temperatures Due to Inoperable Heating
Penalty
Summary
The facility failed to maintain mechanical equipment necessary to heat residents' rooms, resulting in four residents occupying rooms without adequate heating for several months. Observations revealed that one resident was found in the hallway with a blanket over his head and shoulders, shivering and seeking warmth because his room was too cold. Another resident was heard yelling from his room, stating he was cold and requesting that the heat be fixed. Both residents reported that staff had not offered them the option to move to another room despite the lack of heat. The Maintenance Supervisor confirmed that the heating systems in four rooms were not functioning and that the issue had persisted for several months. Room temperatures in these rooms ranged from 66.5°F to 69.7°F, below the facility's policy standard of 71°F to 81°F. The Maintenance Supervisor also stated that there was no documentation indicating residents had been asked to move due to the heating issue. Facility policies reviewed confirmed the requirement to maintain a safe, comfortable, and homelike environment, including appropriate temperature levels.
Failure to Thoroughly Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with impaired cognition and multiple complex medical diagnoses, including anxiety disorder, seizure disorder, malignant neoplasm, delusional disorder, atrial fibrillation, hypertension, and multiple sclerosis. The resident, who was dependent on staff for activities of daily living, alleged that an LPN grabbed her arms during a disagreement, resulting in discoloration. The facility's investigation consisted only of statements from the LPN and the resident, with the LPN attributing the discoloration to the resident being struck by a call light during the incident. No additional witness statements or documentation were collected, and the investigation was closed shortly after the incident was reported. Review of the facility's policy on abuse, neglect, and exploitation indicated that a thorough investigation should include interviews with all involved parties and documentation of all investigative steps. However, the facility's investigation lacked documentation in the resident's progress notes and did not include statements from any other potential witnesses or staff who may have had knowledge of the incident. The administrator confirmed that the investigation was incomplete and did not meet the facility's policy expectations.
Failure to Supervise Resident Smoking and Enforce Smoking Policies
Penalty
Summary
A deficiency was identified when a resident, who had diagnoses including nontraumatic intracerebral hemorrhage, dysphagia, hypertension, major depressive disorder, hyperlipidemia, congestive heart failure, and diabetes mellitus, was observed smoking unsupervised inside the facility in the doorway leading to the courtyard. The resident was cognitively intact but required staff assistance for medication administration, set up with eating, oral hygiene, toilet use, and supervision with bathing. The resident's care plan specified that he was a supervised smoker, with smoking materials to be stored in a designated area and smoking only permitted in designated areas under supervision. However, the resident was able to obtain a cigarette and lighter and smoked inside the facility without supervision, outside of the scheduled smoking times. Staff interviews confirmed that the resident was not supposed to have access to smoking materials and that all smoking was to be supervised and conducted only in the designated courtyard area during scheduled times. The MDS nurse and DON both verified that the facility's policy required smoking items to be kept at the nurse's station and that residents should be supervised when smoking. The facility's smoking policy also prohibited smoking in all areas except the designated smoking area and required safety measures to be in place. Despite these policies, the resident was able to circumvent the rules, resulting in a failure to provide a safe environment and adequate supervision to prevent accidents related to smoking.
Failure to Assist Resident with Medicaid Application After Change in Payor Status
Penalty
Summary
The facility failed to provide a resident with information and assistance regarding how to apply for Medicaid benefits when her skilled care Medicaid coverage ended. The resident, who had multiple complex medical diagnoses including chronic respiratory failure, severe malnutrition, COPD, substance use disorders, and mental health conditions, was admitted to the facility and later received a notice from the Medicaid provider stating she no longer required daily nursing care and could be cared for at a lower level. Despite this change in payor status, the facility did not offer or assist the resident in applying for long-term Medicaid services, as confirmed by interviews with the Business Office Manager and the resident herself. A review of the facility's policy indicated that residents who continue to need LTC services should be provided with the necessary assistance to apply for Medicaid coverage. However, documentation and staff interviews revealed that this assistance was not provided to the resident in question. The facility's failure to act was further highlighted by the lack of explanation from staff as to why the application process was not initiated, despite the resident's ongoing need for care and the facility's stated policy.
Failure to Ensure Safe and Orderly Discharge for Resident with Complex Medical Needs
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident with multiple complex medical conditions, including chronic respiratory failure requiring continuous oxygen, severe malnutrition, COPD, opioid dependence, and mental health disorders. The resident was discharged without arrangements for home health or ongoing oxygen services, and the exact discharge location was unknown to facility staff. Documentation shows that the resident was informed of an immediate discharge due to non-payment and was given a short timeframe to leave, with the threat of police involvement if she did not comply. The resident was provided only a four-hour oxygen tank and had to use her own nasal cannula from the facility. Interviews with staff confirmed that the resident was not offered the opportunity to appeal the Medicaid noncoverage decision, and that necessary services for a safe discharge were not arranged. The resident reported that after her oxygen supply ran out, she was hospitalized for 24 hours and subsequently became homeless. The Ombudsman and Medical Director both confirmed that the facility did not make proper arrangements for a safe discharge, including ensuring a safe destination and provision of required medical services such as home health and oxygen.
Failure to Provide Required Discharge Notice and Notification to Ombudsman
Penalty
Summary
A resident with multiple complex medical conditions, including chronic respiratory failure, severe malnutrition, COPD, opioid dependence, and psychiatric disorders, was discharged from the facility without proper documentation or notification procedures being followed. The medical record lacked formal discharge documentation, and there was no physician note regarding the discharge. Staff interviews confirmed that the resident was discharged to the community without home health or oxygen services arranged, and the exact discharge location was unknown. The resident was not provided with a written discharge notice, nor was a 30-day notice given as required by facility policy. Further, the resident reported being told to leave the facility within 12 hours due to Medicaid payment issues, without being informed of her appeal rights or being given the opportunity to appeal the decision. The Ombudsman confirmed that no discharge notice was provided to their office, and the Medical Director was not involved in or aware of the discharge. Facility policy requires that written discharge notices be provided to the resident, their representative, and the Ombudsman, and that evidence of notification be maintained, but these steps were not followed in this case.
Failure to Maintain Clean and Sanitary Kitchen Environment
Penalty
Summary
During an observation of the kitchen, surveyors found the floor dirty with food crumbs, cracks, and smeared dirt. The trash can was full and lacked a lid, and a hair net was found on the floor next to it. Under the kitchen sink, there was a dirty bath blanket and four towels with a black unknown substance, all piled next to the prep table. Staff interviews confirmed the presence of the blanket and towels, and one staff member reported a significant spillage incident in the kitchen. Review of the facility's policy indicated that the kitchen was required to be maintained in a clean, sanitary, and safe condition, with appropriate equipment such as a step-on trash can and handwashing supplies. These findings indicated the facility failed to maintain a clean and sanitary kitchen environment, potentially affecting all 55 residents who receive food from the kitchen.
Failure to Provide Correct Diet Texture Resulting in Choking Incident
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including pneumonitis, diabetes, and severe cognitive impairment, was not provided the correct diet texture as ordered. The resident was on a pureed diet with thickened liquids due to her medical condition and risk for choking, as documented in her care plan and physician orders. Despite these orders, the resident was able to obtain and consume corn bread, a food item not consistent with her prescribed diet, during a meal in the dining room. The incident unfolded when the resident took corn bread from another resident's plate and asked a nurse supervisor to open it. The nurse supervisor informed the resident that she was on a pureed diet and could not have the corn bread. However, the resident then obtained another piece of corn bread and asked an agency LPN to open it for her. The LPN, unfamiliar with the resident's dietary restrictions, did not verify the resident's diet order and provided the corn bread. Shortly after consuming the corn bread, the resident began to choke and required the Heimlich maneuver from two nurses to resolve the obstruction. Facility policy required staff to verify diet orders before serving food and to ensure residents received the correct diet texture. In this case, the LPN failed to check the resident's diet order before providing the food item, directly leading to the choking incident. The event was documented in progress notes and incident reports, and interviews confirmed that the LPN had not previously cared for the resident and did not check the diet order prior to assisting her.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
A deficiency was identified when the facility failed to implement fall prevention interventions for a resident with multiple diagnoses, including chronic obstructive pulmonary disease, schizophrenia, dementia, and impaired mobility. The resident was assessed as cognitively impaired and required maximal to total assistance with activities of daily living. The care plan included specific fall prevention measures such as placing a floor mat on the open side of the bed, ensuring the call light and personal items were within reach, and providing close staff supervision. During an observation, the resident was found in bed without a call light or personal items within reach, and no floor mat was present next to the bed. The nurse supervisor confirmed these findings. Review of the facility's call light policy indicated that staff were required to ensure the call light was accessible to residents before leaving the room. The failure to follow these interventions and policies led to the cited deficiency.
Oxygen Administration Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure oxygen was administered as ordered by a physician and in accordance with professional standards of practice for respiratory care, affecting three residents. Resident #14, who was cognitively intact and had a history of COPD and chronic respiratory failure, was observed receiving oxygen at two liters per minute (LPM) with outdated tubing and nasal cannula (NC), and there was no signage indicating oxygen use. Similarly, Resident #18, with moderate cognitive impairment and COPD, was receiving oxygen at two LPM with undated tubing and NC, and lacked a physician's order for changing the equipment. There was also no signage on the door indicating oxygen use. Resident #3, who was cognitively intact and had a history of congestive heart failure and asthma, was receiving oxygen at four LPM without a physician's order for oxygen administration or equipment change. The tubing and NC were outdated, and there was no signage indicating oxygen use. Interviews with RN #77 and the Director of Nursing confirmed the deficiencies, and a review of the facility's policy revealed that oxygen administration should include a physician's order and signage indicating oxygen use.
Resident Discharged Without Proper Documentation or Physician's Order
Penalty
Summary
The facility discharged a resident without a physician's order or proper documentation of a rationale for the discharge. The resident, who had severe cognitive impairment and required assistance with activities of daily living, was transferred to another facility without a documented discharge notice or reason in the medical record. The facility's policy required documentation of the reasons for discharge and a physician's order, neither of which were present in this case. The resident's responsible party was informed of the discharge via a phone call and text message, but did not receive a written notice until after the discharge had occurred. The facility sent a 30-day discharge notice via certified mail after the resident had already been transferred. The Medical Director confirmed that she was notified of the discharge but did not document the basis for it or write a discharge order. The facility's policy required such documentation, highlighting a failure to adhere to established procedures.
Failure to Provide Timely Discharge Notice
Penalty
Summary
The facility failed to provide timely written notice of discharge to a resident and their representative, which is a requirement before transferring or discharging a resident. The deficiency involved a resident with severe cognitive impairment and multiple diagnoses, including unspecified encephalopathy, dementia, mood affective disorder, and hypertension. The resident was transferred to another facility without a documented discharge order or a written notice provided to the resident or their representative prior to the discharge. The facility only sent a 30-day discharge notice via certified mail after the resident had already been discharged. Interviews with the resident's responsible party and facility staff confirmed that the discharge notice was not provided in advance. The responsible party was informed of the discharge through a phone call and a text message from the resident's brother, rather than through formal written communication. The facility's policy on transfer and discharge, which was revised after the incident, states that written notice should be provided as soon as practicable before discharge, but this was not adhered to in this case.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to have a Registered Nurse (RN) on duty for eight consecutive hours each day, as required. This deficiency was identified through a review of the staffing schedule for the period from October 26, 2024, to October 31, 2024, which revealed that no RN was scheduled on October 26 and October 27, 2024. This was confirmed during an interview with the President of Operations, who acknowledged the absence of an RN on those dates. The facility census at the time was 52 residents, indicating that the lack of RN coverage had the potential to affect all residents residing in the facility. This deficiency was investigated under Complaint Number OH00159379.
Failure to Maintain Medicaid Coverage for Residents
Penalty
Summary
The facility failed to ensure the maintenance of Medicaid coverage for two residents, resulting in a deficiency. Resident #14, who was cognitively intact and required extensive assistance with activities of daily living (ADLs), had diagnoses including insomnia, psychosis, anxiety, depression, and schizophrenia. Resident #15, who was severely cognitively impaired and required extensive assistance to total dependence with ADLs, had diagnoses including encephalopathy, diabetes mellitus, and cerebral infarction. Both residents were listed as having Medicaid pending as their primary payor source. An interview with the President of Operations confirmed that the facility did not provide the necessary information to maintain ongoing Medicaid coverage, leading to a lapse in coverage for both residents. The facility was in the process of completing new Medicaid applications to reinstate coverage.
Failure to Follow PPE Guidelines for Resident on EBP
Penalty
Summary
The facility failed to ensure staff adhered to guidelines for wearing personal protective equipment (PPE) during care for residents on enhanced barrier precautions (EBP). This deficiency was identified during a review of the care provided to a resident with a catheter, who was on EBP due to the presence of the catheter. The resident, who had diagnoses including depression, neuromuscular dysfunction of the bladder, and paraplegia, required substantial assistance to total dependence with activities of daily living (ADLs). During an observation of catheter care, a Certified Nursing Assistant (CNA) did not wear a gown while providing direct care to the resident, despite the facility's policy requiring staff to wear a gown and gloves during high-contact care activities for residents with indwelling catheters. The CNA confirmed the resident's EBP status and acknowledged the failure to don a gown during the care process.
Failure to Prevent Constipation Leads to Hospitalization
Penalty
Summary
The facility failed to provide adequate care and services to prevent constipation for a resident, resulting in harm when the resident was sent to the hospital for treatment of a large fecal impaction. The resident, who was cognitively intact and required maximum assistance with toileting, had a history of decreased mobility and medication side effects that increased the risk of constipation. Despite these risks, the facility did not implement a toileting program or adequately monitor and address the resident's bowel movements, leading to a significant period without bowel movements. The facility's care plan for the resident included interventions such as administering medications, encouraging high fiber foods, and monitoring bowel movements. However, documentation revealed gaps in bowel movement tracking, with no bowel movements recorded for several days. The facility lacked a policy for constipation management and failed to generate clinical alerts for the absence of bowel movements, resulting in no PRN orders or provider notifications. This deficiency was identified during a complaint investigation and confirmed by facility staff interviews.
Improper Storage of Urine Collection Bag
Penalty
Summary
The facility failed to ensure that urine collection bags were stored in a sanitary manner, as observed with a resident who had an indwelling catheter. The resident, who was admitted with multiple diagnoses including neuromuscular dysfunction of the bladder and hemiplegia, was found with a urine collection bag lying on the floor under the bed. The resident was cognitively intact and required maximum assistance with toileting. The care plan for the resident included specific interventions for catheter care, such as changing the catheter bag as needed and ensuring the tubing was positioned below the bladder. During an observation, it was noted that the urine collection bag was not stored properly, as it was lying on the floor, which was confirmed by a State tested Nurse Aide (STNA). The STNA acknowledged that the bag should have been clipped to the bed and not touching the floor. The resident mentioned that the bag frequently fell on the floor when the bed position was changed, and it had not been emptied since the previous night. The facility's catheter care policy aimed to prevent infection and cross-contamination, but the improper storage of the urine collection bag represented a failure to adhere to this policy.
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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 Cincinnati
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Montgomery Care Center | 1 mi | ★★★★★ | 1 | 0 |
| Twin Lakes | 1.3 mi | ★★★★★ | 0 | 0 |
| Courtyard At Seasons | 1.4 mi | ★★★★★ | 16 | 0 |
| Kenwood Terrace Healthcare Center | 1.7 mi | ★★★★★ | 0 | 0 |
| Chamberlin Healthcare Center | 2.2 mi | ★★★★★ | 10 | 0 |
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