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 Burlington House Rehab & Alzheimer's Care Center during CMS and state inspections, most recent first.
Surveyors found multiple open containers of hazardous cleaning and disinfecting products, including germicidal wipes, sanitizing wipes, bleach wipes, a heavy-duty cleaner with bleach, and waterless hand cleaner, stored in unlocked cabinets, under a desk, and in nurses’ stations on two units. Product labels and SDSs indicated risks such as eye and skin irritation, respiratory irritation, and health hazards if ingested, and the facility’s own policy required hazardous materials to be kept in secure storage when not in immediate use. Facility leadership and an LPN acknowledged that these items should have been locked, and the situation had the potential to affect independently mobile, cognitively impaired residents on the involved units.
A resident with severe cognitive impairment and a history of wandering was found in another resident’s bathroom, where a second cognitively impaired resident with a history of hypersexuality had his hand inside her brief. Both residents showed no distress or response to questioning. The incident occurred despite a physician order for one-on-one monitoring of the resident with hypersexual behaviors, indicating a failure to protect residents from sexual abuse.
The facility failed to ensure a clean environment in the bathrooms of two residents, where a ceiling tile had a large ring of discoloration from an unknown dark substance. This issue, present for at least a month following a water leak, was confirmed by an STNA and a Maintenance Technician, who planned to treat the area with a mold and mildew spray.
A resident with severe cognitive impairment and multiple diagnoses was not provided timely incontinence care as required by their care plan. The resident was not checked or changed from 7:00 A.M. to 2:20 P.M., resulting in a saturated incontinence brief. Staff confirmed the lapse in care due to staffing issues.
The facility failed to provide a clean and sanitary environment for four residents, with issues including brown splatter, foul odors, and gnats in rooms and bathrooms. Housekeeping staff did not clean feces, believing it was the nursing staff's responsibility, and pest control treatments did not include resident rooms.
A resident with severe cognitive impairment and multiple medical conditions was subjected to physical abuse by two STNAs, who were rough during personal care, including throwing a pillow and restraining the resident's hands. The abuse was reported by the resident's private caregiver, substantiated by video evidence, and led to the termination of the involved STNAs.
The facility failed to complete a valid PASARR for a resident with multiple diagnoses, including major depressive disorder, upon admission. The resident had severely impaired cognition and required maximum assistance with toileting and bathing. The social worker confirmed the PASARR was not completed correctly.
The facility failed to ensure that residents with compromised nutrition status were weighed weekly as ordered. This affected three residents, who had various diagnoses including hyperlipidemia, obesity, major depressive disorder, generalized anxiety disorder, Alzheimer's Disease, hypercholesterolemia, protein-calorie malnutrition, orthostatic hypotension, anemia, anorexia, dementia, and vitamin B12 deficiency anemia. Registered staff and a dietitian confirmed the missed weekly weights.
The facility failed to ensure residents were free from unnecessary psychotropic medications, administering Seroquel and Risperdal without adequate indication of use. Two residents with dementia were given these medications despite Black Box Warnings against their use in elderly patients with dementia-related psychosis, and the facility's consultant pharmacist did not review the orders.
Improper Storage of Hazardous Cleaning and Disinfecting Products
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to properly store hazardous chemicals in multiple areas, contrary to its Hazardous Materials Storage policy. On the west unit, an open container of Sani-Cloth Plus Germicidal Disposable Cloths and an open container of Sani-Hands Instant Sanitizing Wipes were observed on the floor under a desk at the nurses’ station. Product labels indicated they should be kept out of reach of children and could be hazardous if swallowed or with certain types of contact. The Executive Director confirmed these wipes should have been locked up. On the south unit, an open container of Sani-Cloth Plus Germicidal Disposable Cloths was found in an unlocked cabinet in the hallway outside the activities area; the LPN present confirmed the container was stored in an unlocked cabinet and that she did not have a key to lock or unlock it. Further observations on the south unit revealed two open containers of Sani-Hands Instant Sanitizing Wipes and an open container of Clorox Healthcare Bleach Germicidal Wipes in the nurses’ station, with the Executive Director confirming these should have been locked. In a south unit dining area, surveyors found an open spray bottle of Ecolab Lemon Lift Heavy Duty Kitchen & Bathroom Cleaner with Bleach in an unlocked cabinet under the sink, along with an open container of Sani-Cloth Germicidal Disposable Cloths and an open container of Clean-n-Mean Waterless Hand Cleaner in an unlocked cabinet above the sink. The Director of Plant Operations confirmed these items should have been locked. Safety Data Sheets for these products documented potential for eye and skin irritation, respiratory irritation, drowsiness or dizziness, and health hazards if ingested or if contacting the eyes. The facility’s policy stated that hazardous materials, including cleaning and disinfecting products, should be stored in a secure storage unit or container when not in immediate use. This deficiency had the potential to affect 28 independently mobile and cognitively impaired residents on the west and south units, within a total facility census of 106 residents.
Failure to Protect Resident from Sexual Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of Alzheimer’s, dementia, and other conditions was not protected from sexual abuse by another resident. The incident took place in a memory care unit, where the resident, who was independently ambulatory and known to wander, entered the bathroom of another resident. This second resident also had severe cognitive impairment and a history of hypersexuality, for which he was receiving medication and had a physician order for one-on-one staff monitoring around female residents. A licensed social worker observed the incident, finding the first resident standing in the bathroom with her pants at her ankles and the other resident, seated in a wheelchair, with his hand inside her brief. Both residents displayed flat affect and did not respond to questioning. The residents were separated without resistance, and the incident was reported to the nurse, police, and the resident’s guardian. The affected resident was sent to the hospital for a Sexual Assault Nurse Exam (SANE), which found no evidence of sexual penetration or injury, but did note incontinence-associated dermatitis. Facility records and interviews confirmed that the resident with hypersexual behaviors had a history of such conduct and was supposed to be under one-on-one monitoring. Despite this, the incident occurred, indicating a failure to ensure adequate supervision and protection for vulnerable residents. The facility’s policy defined sexual abuse as non-consensual sexual contact of any type, and the event was reported as a state reportable incident.
Unsanitary Bathroom Conditions Due to Ceiling Discoloration
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the bathrooms of two residents. During an observation, a ceiling tile in the bathroom shared by these residents was found to have a large ring of discoloration from an unknown dark substance. This issue was confirmed by a State tested Nurse Aide (STNA) who noted that the discoloration had been present for at least a month following a water leak. A subsequent observation confirmed that the discoloration remained unchanged. A Maintenance Technician acknowledged the issue and indicated plans to treat the area with a commercial mold and mildew spray.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident diagnosed with Alzheimer's disease, dementia, epilepsy, hemiplegia, and hemiparesis. The resident was severely cognitively impaired and dependent on staff for all activities of daily living. The care plan required the resident to be checked and changed every two hours due to incontinence of bowel and bladder. However, observations and interviews revealed that the resident was not checked or changed from 7:00 A.M. to 2:20 P.M., resulting in the resident being found with a saturated incontinence brief containing both urine and bowel. Staff interviews confirmed that the resident had not been checked or changed as required during this period due to staffing issues. The resident's daughter, who visited daily, reported that she had asked staff to check and change her mother around noon because she smelled like urine, but was told it would be done after 2:00 P.M. The facility's policy on routine resident care emphasized the importance of maintaining skin integrity and providing timely incontinence care, which was not adhered to in this case. This deficiency was identified during an investigation of complaints numbered OH00153822 and OH00153607.
Failure to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to provide residents with a clean and sanitary environment, affecting four residents. Resident #06's room had brown splatter on the wall, ceiling, floor, and toilet, which the housekeeper identified as potentially feces but did not clean, believing it was the nursing staff's responsibility. Resident #10's room had a strong foul odor, brown water, and splashed brown substance around the toilet seat, with active flying gnats present. The Housekeeping Manager confirmed these observations but did not address the issue immediately. Resident #48's room had an extra mattress leaning against the wall, a sticky substance on the bedside table, and a soiled bathroom trash can with brown splatter. The toilet seat was dirty with numerous gnats flying around. Resident #80's bathroom had a smudged brown substance identified as feces around the toilet and on the toilet seat, which the housekeeper did not clean, believing it was not her responsibility. The Administrator confirmed that housekeeping staff are expected to clean feces from the toilet, while nursing staff clean feces from the floor. The facility's pest control treatments did not include resident rooms, and the housekeeping policy for cleaning washrooms was not followed properly.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to ensure a resident was free from physical abuse, affecting one resident out of two reviewed for abuse. The resident, who had severe cognitive impairment and required maximum assistance with daily activities, was subjected to physical abuse by two State Tested Nurse Aides (STNAs). The abuse was reported by the resident's private caregiver, who provided a video showing the STNAs being rough during personal care, including throwing a pillow at the resident and restraining her hands. The facility's investigation substantiated the abuse, leading to the termination of the involved STNAs and notification of the police. The resident's medical history included hydrocephalus, osteoarthritis, schizoaffective disorder, hypothyroidism, hyperlipidemia, major depressive disorder, anxiety disorder, dementia, and hypertension. The resident was known to exhibit behaviors such as increased agitation, verbal and physical aggression, and resistance to care, which were documented in her behavior care plan. Despite these challenges, the facility's policy required staff to approach the resident calmly, attempt to determine underlying causes of behaviors, and protect the resident's rights and safety. On the day of the incident, the resident's private caregiver reported the abuse to the Administrator, who immediately suspended the STNAs and initiated an investigation. The video footage confirmed the rough handling and inappropriate actions by the STNAs. The resident was later evaluated at the hospital and diagnosed with a urinary tract infection but had no injuries from the abuse incident. The facility's policy emphasized the prevention of abuse, mistreatment, or neglect of residents, which was not adhered to in this case.
Failure to Complete Valid PASARR
Penalty
Summary
The facility failed to ensure a valid Preadmission Screening and Resident Review (PASARR) was completed upon admission for a resident. The resident, who had diagnoses including diabetes mellitus type 2, lymphedema, essential primary hypertension, anxiety disorder, post-traumatic stress disorder (PTSD), adjustment disorder, heart failure, major depressive disorder, and chronic kidney disease stage 2, was admitted to the facility. A review of the most recent Minimum Data Set (MDS) assessment revealed the resident had severely impaired cognition and required maximum assistance with toileting and bathing. The PASARR review dated 03/13/24 did not identify the resident's mental health diagnosis of major depressive disorder. The facility's social worker confirmed that the PASARR was not completed correctly and did not assess the resident's major depressive disorder.
Failure to Obtain Weekly Weights for Residents with Compromised Nutrition
Penalty
Summary
The facility failed to ensure that residents with compromised nutrition status were weighed weekly as ordered. This deficiency affected three residents. Resident #70, who had diagnoses including hyperlipidemia, obesity, major depressive disorder, and generalized anxiety disorder, had an order for weekly weights starting from 02/16/2024. However, weights were only recorded on 02/05/2024, 03/05/2024, 03/22/2024, and 04/03/2024. Registered Nurse #36 confirmed that weekly weights were not being completed due to a lack of prompt in the Medication Administration Record (MAR). Dietitian #98 also confirmed the missed weekly weights for Resident #70. Resident #33, diagnosed with Alzheimer's Disease, hypercholesterolemia, major depressive disorder, protein-calorie malnutrition, orthostatic hypotension, anemia, and anorexia, also had an order for weekly weights from 02/16/2024. However, weights were only documented on 02/07/2024, 03/07/2024, 04/05/2024, and 05/01/2024. Similarly, Resident #85, diagnosed with dementia, vitamin B12 deficiency anemia, and unspecified protein-calorie malnutrition, had an order for weekly weights from 02/16/2024. Weights were recorded on 02/05/2024, 03/05/2024, 03/31/2024, 04/03/2024, 04/30/2024, and 05/01/2024. Registered Dietitian #98 confirmed that weekly weights were not being obtained as ordered for both Resident #33 and Resident #85. The facility's policy stated that weights should be obtained monthly or as ordered by the physician, which was not adhered to in these cases.
Inappropriate Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure residents were free from unnecessary psychotropic medications, as evidenced by the administration of antipsychotic medications without adequate indication of use. Resident #66, who was admitted with diagnoses including Alzheimer's disease, dementia with behavioral disturbance, and unspecified psychosis, was prescribed Seroquel for dementia with behavioral disturbance and psychosis. However, this diagnosis is not clinically indicated for the use of Seroquel, which has a Black Box Warning against use in elderly patients with dementia-related psychosis due to increased cardiovascular mortality risks. The Director of Nursing confirmed the inappropriate administration of Seroquel for Resident #66. Similarly, Resident #349, admitted with diagnoses including Alzheimer's disease, dementia with agitation, and anxiety disorder, was prescribed Risperdal for dementia with behavioral disturbance. The facility's consultant pharmacist did not review the Risperdal order, and the Regional Nurse confirmed the inappropriate use of Risperdal for this diagnosis. Risperdal also carries a Black Box Warning against use in elderly patients with dementia due to increased cardiovascular mortality risks. Both cases highlight the facility's failure to adhere to guidelines for the use of psychotropic medications in elderly residents with dementia.
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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) |
|---|---|---|---|---|
| Home At Hearthstone, The | 1.5 mi | ★★★★★ | 1 | 0 |
| Mt Healthy Christian Home | 1.5 mi | ★★★★★ | 0 | 0 |
| Home At Taylor's Pointe | 1.6 mi | ★★★★★ | 0 | 0 |
| Triple Creek Retirement Community | 1.8 mi | ★★★★★ | 1 | 0 |
| Alois Alzheimer's Care Center | 2.1 mi | ★★★★★ | 7 | 0 |
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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.