Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Covenant Village Care Center during CMS and state inspections, most recent first.
Unsanitary kitchen conditions were observed, including black spots on the ice machine, dust-like buildup on the kitchen hood, and uncovered garbage cans in the dish room and kitchen. During tray line service, an employee used a thermometer probe on multiple food items and wiped it with a glove between items instead of sanitizing it. The DD and RMD confirmed the cleaning schedules for the ice machine and hood, and the facility policy did not provide guidance on taking food temperatures.
Dining Dignity Failure During Assisted Feeding: Staff failed to maintain resident dignity during lunch when two CNAs were observed standing over two dependent residents while feeding them at the dining table. One resident had Huntington's disease, ataxia, and dysphagia with severe cognitive impairment, and the other had epilepsy, Alzheimer's disease, and Down syndrome with severe cognitive impairment; both required assistance with feeding, and both CNAs confirmed the observations.
An unlocked medication cart was observed on the 100 hall with no staff nearby, and a severely cognitively impaired resident was within four feet of it. The DON confirmed the cart was unlocked and the resident was in close proximity. Facility policy required medications to be stored in a locked cabinet, cart, or medication room.
Wound care supplies of calcium alginate were observed stored in a plastic bag on the floor of a medical storage room. A resident with a cervical spinal cord lesion, paraplegia, and a stage 3 pressure ulcer had an order for daily wound care using calcium alginate, and the DON confirmed the supplies were on the floor and should not have been stored there. CDC guidance cited in the report states sterile supplies should be kept 8 to 10 inches off the floor.
A resident with multiple medical conditions, moderately impaired cognition, and a court-appointed guardian was discharged home without guardian approval and with HHC arranged only on the day of discharge. Documentation showed the resident required assistance with ADLs and had functional decision-making impairments, yet social services recorded that the resident insisted on going home, refused LTC placement, and arranged transportation with a family member. Discharge notes indicated instructions and medications were provided, but interviews confirmed that the guardian did not authorize the discharge and that the timing of the HHC referral did not follow the facility’s usual practice, resulting in a failure to ensure a safe and orderly discharge as required by facility policy.
A resident admitted with multiple medical conditions, including a displaced humerus fracture and rheumatic mitral stenosis, had hospital discharge orders and facility orders for PRN Oxycodone for pain but went 36 hours without receiving it. The baseline care plan completed within 48 hours of admission did not assess or address the resident’s pain or documented hearing loss with use of hearing aids, despite the resident being cognitively intact and reporting excruciating pain and hearing impairment. An MDS coordinator later confirmed that pain management and hearing loss should have been included in the baseline care plan, contrary to facility policy requiring essential healthcare information in baseline care plans.
Surveyors found that the facility failed to assess and care plan activity needs for two residents whose CAAs triggered activities as a care area. Both residents had severe cognitive impairment and required significant assistance with ADLs, and activity assessments had been completed, but their care plans contained no activity-related goals or interventions. The Activities Director acknowledged there were no ongoing documented activity preferences or assessments for these residents, and the DON confirmed that activities were not included in their care plans and that no quarterly activity assessments had been done, despite facility policies requiring comprehensive, person-centered care plans and routine activity evaluations.
A resident with multiple medical conditions, including a displaced fracture of the upper left humerus, was admitted with hospital orders for PRN oxycodone for pain. Facility physician orders continued PRN oxycodone for fracture-related pain, but due to the prescription being sent to a specialty pharmacy without a required signature, the medication was not available for approximately 36 hours. During this time, the resident reported excruciating pain, and the MAR showed the first oxycodone dose was not given until two days after the facility order, with a documented pain level of nine. This failure to ensure timely availability of ordered PRN pain medication resulted in a deficiency related to pain management.
A resident with severe cognitive impairment and multiple neurologic and medical diagnoses, including Huntington's disease, ataxia, corticobasal degeneration, and dysphagia, was found living in a room where the floor was covered with small white spots resembling paint chips and the walls around the bed had multiple areas of worn paint and black scuff marks. During an observation with the Maintenance Director and Administrator, both confirmed the walls and floor should have been repaired before reaching this condition. Review of the facility's Environmental Services Inspection policy showed it required regular monitoring, random or routine inspections, and immediate correction of issues to maintain a safe and sanitary environment, which was not followed in this instance.
A resident requiring maximum assistance and using a wheelchair was sent to an oral surgery appointment without an escort, dressed only in hospital gowns and socks during cold weather, and left unattended in a medical center lobby. Facility staff were unaware of the appointment, and available donated clothing was not used.
A resident at risk for pressure ulcers developed a stage III ulcer due to inadequate skin assessments and monitoring. Despite interventions in place, the facility failed to identify the ulcer until it reached an advanced stage, as confirmed by a WNP. The deficiency was investigated under a complaint, revealing non-compliance with pressure ulcer prevention standards.
Unsanitary kitchen conditions and improper food temperature monitoring
Penalty
Summary
Food was not stored, prepared, and served under sanitary conditions in the kitchen. During observation, the inside upper lip of the ice machine had small black spots that wiped off with a clean paper towel. The Dietary Director confirmed the black spots were present and stated maintenance managed the cleaning schedule for the ice machine. The Regional Maintenance Director confirmed the ice machine was on a six-month cleaning cycle, and maintenance records showed it had been cleaned on 06/19/25 and 12/22/25. The facility policy required the ice machine to be defrosted, dismantled, cleaned, and disinfected every six months or more often if needed. The kitchen hood above the stove, oven, and fryer had a layer of brown particulate that appeared to be dust on the light covers and front inside wall. The Dietary Director confirmed these areas needed cleaning, and the Regional Maintenance Director stated the hood was cleaned on 08/27/25 and 02/23/26, with a six-month cleaning schedule in place. In addition, multiple garbage cans in the dish room and kitchen did not have lids or covers, and the Dietary Director confirmed lids were not available for those cans. During tray line service, a staff member inserted a thermometer probe into mixed vegetables, pureed mixed vegetables, pureed hamburger, and mechanical soft hamburger, wiping the probe with a rubber glove between items rather than sanitizing it. The staff member confirmed this practice, and the facility policy did not include guidance on obtaining food temperatures.
Dining Dignity Failure During Assisted Feeding
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity during dining when staff stood over residents while feeding them lunch. This deficiency affected two residents out of 24 reviewed for dining observation in a facility with a census of 104. Resident #26 had diagnoses including Huntington's disease, ataxia, and dysphagia, and was documented as dependent for eating and requiring one-person assistance with feeding. The minimum data set assessment also indicated the resident was severely cognitively impaired and dependent on staff for bringing food and/or drink to the mouth. Resident #48 had diagnoses including generalized idiopathic epilepsy and epileptic syndromes, Alzheimer's disease, and Down syndrome. The care plan stated the resident required one-person assistance with feeding, and the minimum data set assessment indicated severe cognitive impairment and substantial/maximal assistance with bringing food and/or drink to the mouth. During observation in the main dining room, CNA #91 was seen standing over Resident #48 while feeding her lunch, and CNA #141 was seen standing over Resident #26 while feeding him lunch. Both CNAs confirmed in interview that they fed the residents while standing over them at the dining table. Facility policy titled Dignity stated the facility would promote resident dignity in dining.
Unlocked Medication Cart Observed on 100 Hall
Penalty
Summary
Medication storage was not maintained in a locked condition when the 100 hall medication cart was observed unlocked with no staff nearby, and Resident #84 was within four feet of the cart. Resident #84 was admitted with diagnoses including rhabdomyolysis, metabolic encephalopathy, and ischemic cardiomyopathy, and the MDS described the resident as severely cognitively impaired, wheelchair dependent, and without impairment in the upper or lower extremities. During the observation, the Director of Nursing confirmed that the medication cart was unlocked and that Resident #84 was in close proximity to it. Facility policy titled "5.0 Medication Storage" stated that all medications are to be stored in a locked cabinet, cart, or medication room.
Wound Care Supplies Stored on Floor
Penalty
Summary
Provide and implement an infection prevention and control program was not maintained when wound care supplies of calcium alginate were observed stored in a plastic bag on the floor of the medical storage room on the 100 hall. Resident #5, who was admitted with diagnoses including complete lesion at C2 level of the cervical spinal cord, paraplegia, and a stage 3 pressure ulcer of the right hip, had a physician order for daily wound care to the left ischium using saline, collagen sprinkles, calcium alginate, and a silicone foam dressing. The resident’s MDS indicated the resident was cognitively intact, had upper and lower extremity impairment on both sides, used an electric wheelchair, required substantial to maximal assistance with toileting hygiene, and was dependent for chair/bed-to-chair transfers. During observation, thirty packs of calcium alginate were seen stored on the floor, and the DON confirmed the supplies were on the floor and stated wound care supplies should not be stored there. CDC guidance cited in the report states sterile supplies should be stored 8 to 10 inches from the floor and packages that fall on the floor must be inspected for damage.
Failure to Ensure Safe Discharge for Resident Under Guardianship
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe discharge for a resident who had a court-appointed guardian and documented cognitive impairment. The resident, admitted with diagnoses including atrial fibrillation, depression, mental disorder, hemiplegia and hemiparesis following cerebral infarction, and essential hypertension, had a recent MDS showing moderately impaired cognition (BIMS score of eight) and needed assistance with eating, toileting, bathing, and personal hygiene. A Letter of Guardianship documented that the resident was incompetent for an indefinite period. The discharge summary stated the resident was discharged home with functional impairments in decision-making, that the son would provide transportation, and that discharge paperwork was reviewed with the patient. Social service notes on the day of discharge documented that the resident’s daughter had been called regarding a lost appeal, that the resident was to discharge home with HHC and transportation by his son, and later that the resident was discharged home with his brother, with discharge instructions reviewed and paperwork signed. Further review and interviews revealed that the HHC referral for the resident was not sent until the day of discharge, whereas the social service assistant stated such referrals usually occur prior to the day of discharge. The HHC notification showed HHC was planned and accepted on the same day as discharge. The social service assistant and the Administrator confirmed that the resident’s guardian did not give approval for the resident to discharge home and that the resident arranged his own transportation, stating he would call his brother. A subsequent social service note documented that the resident was adamant about returning home and refusing LTC placement or transfer, and that, based on discussion with the resident, there was no evidence he was incompetent to make his own decisions, and that he verbalized the risks of living alone. The facility’s Transfer and Discharge policy required orientation and documentation to ensure a safe and orderly transfer or discharge in a form and manner the resident could understand. The survey found the facility failed to ensure a safe discharge for this resident, who was under guardianship and discharged home without guardian approval, with HHC arranged only on the day of discharge.
Failure to Include Pain Management and Hearing Loss in Baseline Care Plan
Penalty
Summary
The facility failed to develop a complete baseline care plan within 48 hours of admission that addressed pain management and hearing loss for one resident. The resident was admitted with multiple diagnoses, including discoid lupus erythematosus, depression, polyarthritis, cardiac arrhythmia, cervical disc disorder, a displaced fracture of the upper end of the left humerus, and rheumatic mitral stenosis. The resident’s MDS 3.0 assessment in progress indicated the resident was cognitively intact. Review of the baseline care plan showed that pain and hearing loss, including the use of a hearing aid, were not assessed or incorporated into the plan, despite the resident’s conditions and needs. Record review showed a hospital discharge order for Oxycodone immediate release 5 mg every four hours as needed, and a facility physician order for Oxycodone 5 mg every six hours as needed for pain related to the left humerus fracture. The resident reported experiencing excruciating pain and stated that the facility was unable to provide the Oxycodone for 36 hours. The resident also reported having hearing loss and wearing hearing aids. The MDS coordinator confirmed that the baseline care plan did not include pain or hearing loss and acknowledged that these should have been included. Facility policy on care planning required that the baseline care plan include the minimum healthcare information necessary to properly care for a resident.
Failure to Assess and Care Plan Residents’ Activity Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement complete, person-centered care plans that addressed residents’ activity needs with measurable goals and interventions. For one resident with diagnoses including dizziness, chronic embolism and thrombosis of an unspecified vein, dysphagia, Alzheimer’s disease, and anxiety disorder, the most recent MDS showed severe cognitive impairment and total dependence for eating, bathing, and personal hygiene. The Care Area Assessment (CAA) for this resident triggered activities as a care area requiring care planning, and an activity assessment had been completed; however, the resident’s care plan contained no goals or interventions related to activities. A second resident, with diagnoses including Huntington’s disease, essential hypertension, ataxia, corticobasal degeneration, cognitive communication deficit, and dysphagia, also had an MDS indicating severe cognitive impairment and the need for partial or substantial assistance with eating, toileting, bathing, and personal hygiene. The CAA for this resident likewise triggered activities for care planning, and an activity assessment had been completed, but the care plan did not include any activity-related goals or interventions. The Activities Director reported there were no documented ongoing activity preferences or assessments for these two residents, and the DON confirmed that activities were not included in their care plans and that no quarterly activity assessments had been completed, contrary to the facility’s written Care Plan and Activities policies. This deficiency was investigated under Complaint Number 2700708.
Failure to Ensure Availability of Ordered PRN Pain Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure ordered pain medication was available for a resident who required pain management. The resident was admitted with multiple diagnoses, including discoid lupus erythematosus, depression, polyarthritis, cardiac arrhythmia, cervical disc disorder, a displaced fracture of the upper end of the left humerus, and rheumatic mitral stenosis. Hospital discharge orders dated 03/19/26 included Oxycodone immediate release 5 mg every four hours as needed. Facility physician orders dated 03/27/26 at 2:45 P.M. specified Oxycodone 5 mg orally every six hours as needed for pain related to the displaced fracture of the left humerus. Review of the MAR showed that Oxycodone was first administered on 03/29/26 at 8:55 A.M., at which time the resident’s pain level was documented as nine. The resident reported during interview that upon admission she experienced excruciating pain and was unable to receive Oxycodone, stating the facility could not provide it for 36 hours. The DON confirmed that the resident arrived with an Oxycodone order from the hospital and that the prescription was sent to the specialty pharmacy without a signature, resulting in the ordered Oxycodone not being available from 03/27/26 to 03/29/26. During this period, the resident did not have access to the prescribed pain medication. The facility’s pain assessment and management policy, dated 08/2025, directed staff to review the MAR to determine how often an individual requests and receives PRN pain medication and the extent to which administered medications relieve the resident’s pain. This deficiency was investigated under Complaint Numbers 2788877 and 2722512.
Failure to Maintain Sanitary Resident Room Environment
Penalty
Summary
The facility failed to ensure a sanitary environment in a resident room, resulting in noncompliance with requirements to maintain a safe, clean, and comfortable area for residents, staff, and the public. The affected resident had diagnoses including Huntington's disease, essential hypertension, ataxia, corticobasal degeneration, cognitive communication deficit, and dysphagia. The most recent MDS 3.0 assessment documented severe cognitive impairment and a need for partial assistance with eating and personal hygiene, and substantial assistance with toileting and bathing. These clinical details establish that the resident was dependent on staff and the facility environment for safe and sanitary living conditions. During an observation and interview in the resident’s room with the Maintenance Director and the Administrator, surveyors noted the floor was covered with small white spots that appeared to be paint chips stuck to the floor. They also observed multiple areas of worn paint and scuffing on the walls: paint worn off about six inches by twelve inches near the footboard, paint worn with black scuff marks about twelve inches by eighteen inches near the top bed rail, and paint worn off about one inch by eight inches near the headboard. The Maintenance Director confirmed that the walls and floor should have been repaired before reaching this condition. Review of the facility’s “Environmental Services Inspection” policy, dated 12/2025, showed that the facility was supposed to regularly monitor environmental services, perform random and/or routine inspections, and correct all identified opportunities immediately, which did not occur in this case.
Resident Sent to Appointment Unattended and Inappropriately Dressed
Penalty
Summary
A deficiency occurred when a resident with a zygomatic fracture and depression, who required maximum assistance with toileting and dressing and used a wheelchair, was sent to an oral surgery appointment without appropriate clothing or an escort. The resident was dropped off by a transport company and left unattended in the medical center lobby, dressed only in two hospital gowns and socks during cold winter weather, with no paperwork or clear understanding of the appointment. Staff at the oral surgery office found the resident unaccompanied and unsure of her purpose for being there. Facility staff interviews revealed a lack of awareness regarding the resident's appointment, and the nursing supervisor was not informed until contacted by the oral surgery office. The resident was sent out without an escort, and staff confirmed she did not have her own clothing. Although the facility maintained a supply of donated clothing for residents without personal clothes, this resource was not utilized. The weather on the day of the appointment was notably cold, with temperatures ranging from 18 to 25 degrees Fahrenheit.
Failure to Prevent and Timely Identify Pressure Ulcer
Penalty
Summary
The facility failed to adequately assess and monitor the skin condition of Resident #104, who was admitted without pressure ulcers but was at risk for developing them. Despite being identified as at risk for impaired skin integrity due to fragile skin and incontinence, the resident's care plan included interventions such as applying a moisture barrier, using a pressure-reducing mattress, and conducting regular skin checks. However, daily nurse assessments from 10/24/24 to 11/04/24 did not document any skin impairments, and the resident's Braden Scale assessment on 10/31/24 indicated a low risk for pressure ulcers. On 11/04/24, a CNA informed LPN #69 of two new open wounds on the resident's buttocks, which were subsequently assessed and treated by the nurse. The wounds were not identified until they had progressed to a stage III pressure ulcer, as confirmed by WNP #175 on 11/05/24. The pressure ulcer on the resident's left gluteus measured 7 cm by 4 cm by 0.3 cm, with exposed subcutaneous tissue and eschar present. The facility's policy required weekly skin assessments and more frequent checks if indicated, but these were not effectively implemented, leading to the late identification of the pressure ulcer. Interviews with the DON and LPN #68 confirmed that the pressure ulcer was facility-acquired and not identified until it reached an advanced stage. The facility's failure to conduct thorough and timely skin assessments, as outlined in their policy and NPIAP guidelines, contributed to the development and progression of the pressure ulcer. The deficiency was investigated under Complaint Number OH00159654, highlighting non-compliance with pressure ulcer prevention and care standards.
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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) |
|---|---|---|---|---|
| Terrace View Gardens | 1.7 mi | ★★★★★ | 6 | 0 |
| Mt Airy Gardens Rehabilitation And Nursing Center | 2.2 mi | ★★★★★ | 0 | 0 |
| Bridgetown Nursing And Rehabilitation Centre | 2.2 mi | ★★★★★ | 2 | 0 |
| Hillebrand Nursing And Rehabilitation Center | 2.3 mi | ★★★★★ | 16 | 0 |
| Lakeridge Villa Health Care Center | 2.3 mi | ★★★★★ | 0 | 0 |
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