Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Garden Park Health Care Center during CMS and state inspections, most recent first.
Failure to follow contact precautions for a resident with MRSA bacteremia occurred when an LPN entered the room of a cognitively intact resident with an active contact isolation order and donned gown and gloves only after entering. No contact isolation sign was posted, the resident was sharing a room with another resident who did not have MRSA, and the ADON confirmed the sign had been removed and not replaced with contact precautions.
A resident with diagnoses including infective endocarditis, hepatitis C, severe sepsis, and pneumonia had an order for IV cefazolin three times daily, but the first documented dose was not given until several days after admission, resulting in six missed doses. Review of the MAR and nurse notes showed no documentation that the physician was notified of the missed doses or that the pharmacy was contacted about medication delivery. The pharmacist later confirmed the antibiotic was delivered, and the DON acknowledged the missed doses and lack of documentation, contrary to the facility’s medication administration policy requiring timely administration as prescribed.
Several residents did not receive their prescribed medications, including Potassium, Buprenorphine, Zoloft, and Levetiracetam, because the medications were not available during the scheduled administration. An LPN confirmed the omissions during medication pass, and facility policy requires medications to be reordered in advance to prevent such occurrences.
Failure to Complete Annual CNA Performance Evaluations: The facility did not ensure annual performance evaluations were completed for two CNAs. Personnel record review showed both CNAs had no documented evaluations during the required period, and HR verified the evaluations had not been completed. The facility policy stated employee job performance should be reviewed and evaluated at least annually.
TB screening and medication handling deficiencies were identified. Several newly hired employees did not have the required two-step TB skin test upon hire, and HR confirmed the omission. During a medication pass, an RN handled residents’ oral medications with bare hands before administration, which she acknowledged. Facility policy required TB screening for all employees and stated that oral medications should not be touched with ungloved hands.
Missing Annual CNA In-Service Training: The facility failed to ensure CNAs received the required 12 hours of annual in-service education. Record review showed three CNAs had no documented annual in-service training for the applicable review periods, and HR confirmed the missing documentation. The facility policy required all CNAs to complete a minimum of 12 hours of in-service training each year.
Staff failed to promptly report multiple incidents of resident-to-resident sexual abuse to the state agency, including situations involving cognitively impaired residents and public sexual activity. Although staff separated the involved residents and documented the events, the required notifications and investigations were delayed, contrary to facility policy and regulatory requirements.
The facility did not promptly or thoroughly investigate multiple incidents of resident-to-resident sexual abuse, including one involving a cognitively impaired resident and another involving two residents engaging in sexual activity in a public area. Staff failed to immediately report the incidents, did not conduct timely interviews or obtain witness statements, and did not assess the residents' capacity to consent, resulting in delayed and incomplete investigations.
A resident with impaired cognition and multiple medical conditions did not receive appropriate hand and nail hygiene, resulting in excessively long and dirty fingernails that interfered with the use of a communication device. Staff interviews confirmed that nail care was only performed during scheduled showers and was not consistently documented or offered outside of those times, contrary to facility policy.
A resident with a history of falls and multiple medical conditions was identified as needing a fall mat beside the bed per care plan and physician order. Despite this, repeated observations and staff interviews confirmed the fall mat was not in place while the resident was in bed, contrary to facility policy and documented interventions.
The facility failed to notify the Ombudsman of a resident’s hospitalization and discharge. The resident was cognitively intact and needed staff help with ADLs, but the record did not show Ombudsman notification, and the Administrator confirmed the notification was not made. Facility policy required notice to the LTC Ombudsman as soon as practicable.
Inaccurate MDS Coding for Falls and Left-Hand Contracture: A resident with diabetes, CKD, depression, and spastic hemiplegia had multiple documented falls during the stay, but the MDS underreported the fall history. The resident also had a left-hand deformity/partial contracture present throughout the stay, yet the MDS did not accurately code the impairment. The DON, DOT, and MDS LPN confirmed the inaccurate coding and the lack of documentation for the hand deformity.
PASARR screening was not accurately completed for a newly admitted resident with diagnoses including schizoaffective disorder, bipolar disorder, radiculopathy, and CHF. The resident was moderately cognitively impaired and needed staff help with ADLs, but the PASARR did not include or mark the schizoaffective disorder diagnosis. The Administrator and SSD both verified the omission.
Failure to care plan a resident's left-hand contracture. The resident was admitted with multiple diagnoses and had a pre-existing hand injury that caused a deformity, but the care plan did not address the contracture. Observation showed the resident's left hand digits were crossed and could not be extended, and the DON and DOT confirmed there was no documentation, therapy notes, assessments, or recommendations for the condition. The MDS LPN also confirmed the MDS coding was not correct for the hand contracture.
Smoking care plans were not updated for two residents. One resident with multiple sclerosis and other diagnoses was documented inconsistently as needing supervision, while he reported smoking at will and managing his own cigarettes and lighters; the AD said the facility considered him an independent smoker, but the care plan was not revised. Another resident with COPD and acute respiratory failure had an unscored smoking assessment, mild cognitive impairment, and needed staff help with oxygen tubing, lighting cigarettes, and holding them, yet the care plan lacked specific safe-smoking interventions.
Failure to provide treatment for a resident’s hand contracture. A resident admitted with multiple diagnoses had a left-hand deformity/partial contracture present throughout the stay, but the care plan did not address it and MDS assessments did not code the impairment correctly. Observation showed the resident’s left hand digits crossed and limited extension, and the DON and DOT confirmed there was no documentation, therapy assessment, or recommendations for the contracture.
Improper Labeling of Insulin Pens: Surveyors found insulin pens in medication carts that were unlabeled, missing open dates, or not labeled with the correct resident name. An ADON confirmed an unlabeled insulin pen in one cart and multiple open insulin pens in another cart, including pens for three residents that lacked required labeling information.
A facility failed to maintain a clean and safe environment, affecting 36 residents. Observations revealed a resident's room with dirty linen, damaged walls, and a sticky floor. The main corridor had exposed light fixtures and missing handrail endcaps. The resident, with multiple diagnoses, expressed dissatisfaction with her room's condition. The facility's policy on providing a homelike environment was not followed.
The facility's dishwasher was not maintained properly, affecting all 46 residents who received food from the kitchen. The dishwasher's wash and rinse temperature was 120°F, and it lacked the necessary chemical sanitizer, registering at zero ppm. The Dietary Manager confirmed the deficiency, which was investigated under a complaint.
The facility failed to notify the state mental health authority of significant changes in the mental health conditions of two residents, as required by PASARR. One resident was diagnosed with adjustment disorder and another with depression, but the facility did not complete the necessary PASARR updates or notifications. This non-compliance was confirmed during an interview with the Social Services Director.
The facility failed to develop comprehensive care plans for two residents, one lacking a dental care plan despite being edentulous, and another without plans for a prosthetic limb and activities. Both residents were cognitively intact, and the deficiencies were confirmed by the MDS Coordinator.
A resident with a below-the-knee amputation experienced prolonged issues with a poorly fitting prosthesis, which the facility failed to address in a timely manner. Despite receiving a prosthesis, the resident reported discomfort and pain, leading to an inability to use it effectively. The facility did not follow up on the prosthesis issues for several months, and the resident's insurance was not billed for the original prosthesis. The Director of Rehabilitation later discovered these issues and initiated steps to resolve them.
A resident with intact cognition reported a theft of two hundred dollars from their room to an LPN, who documented the incident and informed the administration. However, the facility failed to report this allegation to the Ohio Department of Health as required by their policy, which mandates timely investigation and reporting of such incidents.
The facility failed to maintain medication error rates below five percent, with an observed error rate of 11.1%. Three residents were affected due to unavailable medications and improper administration techniques. An LPN confirmed the errors, which included not administering loratadine, amiodarone, and Claritin due to unavailability, and not priming a Lantus insulin pen before use.
The facility failed to maintain a safe and clean environment for its 46 residents, with issues such as inadequate lighting, broken and discolored ceiling tiles, cobwebs, dust, debris, and dead bugs in common areas. Residents' rooms had water-damaged windows, requiring towels to soak up rainwater, and the 200-hall lacked handrails. The kitchen and dining areas had missing ceiling tiles and dead bugs in light fixtures, while the 300-hall had broken tiles and mold-like discoloration. Interviews with staff and residents confirmed these persistent issues.
The facility failed to maintain food safety and sanitation standards, affecting all 46 residents. Observations revealed unsanitary conditions in the kitchen, including food debris on trash cans and mold-like substance on wall tiles. Additionally, a dietary staff member did not sanitize the food thermometer between uses on different food items, contrary to the facility's sanitation policy.
The facility failed to maintain essential equipment, affecting two residents and potentially all 46 residents due to a malfunctioning dishwasher. A resident's bed was broken, causing discomfort and safety issues, while another's bed had a spliced electrical cord, preventing necessary movement for care. The dishwasher failed to reach required sanitization temperatures, with no effective maintenance or documentation of repairs.
The facility failed to provide secured handrails in the hallway of the 200 unit, potentially affecting 15 independently mobile residents. During a tour, it was observed that no handrails were affixed to the walls. The Administrator confirmed this absence, stating that the unit was being remodeled and handrails needed to be ordered. This issue was investigated under multiple complaint numbers.
Failure to Follow Contact Precautions for Resident with MRSA
Penalty
Summary
The facility failed to follow contact precautions for a resident with MRSA bacteremia and an active physician order for contact isolation requiring a single room and all services rendered in the room only. Resident #78 was cognitively intact, had an order for contact isolation, and also had an order for daily wound care to the left lower calf and IV daptomycin for MRSA bacteremia. On 05/14/26, personal protective equipment was observed in drawers outside the room, but no contact isolation sign was posted outside the door. An LPN entered the room to provide wound care and did not don gown and gloves until after entering the room. At the time of the observation, Resident #78 was sharing a room with Resident #44, and Resident #44 was asleep in bed. The LPN confirmed she did not put on gown or gloves until after entering the room and stated she was not aware of the contact isolation order because there was no sign on the door. The ADON confirmed the two residents were roommates and that no contact precautions sign was posted, stating the sign had been removed the day prior when the walls were being painted and only an Enhanced Barrier Precautions sign had been replaced. The DON confirmed Resident #78 had active MRSA and an active order for contact isolation in a single room, and that Resident #44 did not have MRSA.
Failure to Timely Administer Ordered IV Antibiotic and Notify Physician/Pharmacy
Penalty
Summary
The facility failed to ensure timely delivery and administration of an ordered IV antibiotic for a resident, resulting in multiple missed doses without appropriate follow-up. The resident was admitted with diagnoses including infective endocarditis, hepatitis C, severe sepsis, and pneumonia, and had a physician’s order dated 02/28/26 for cefazolin sodium IV solution, two grams IV three times a day until 03/31/26. The resident’s MDS showed the resident was cognitively intact and required supervision with ADLs, and the care plan documented IV medications related to endocarditis. Review of the MAR for February and March 2026 showed that the first documented dose of cefazolin was not administered until 03/01/26 at 10:00 P.M., and that six scheduled doses on 02/27/26 at 10:00 P.M.; 02/28/26 at 6:00 A.M., 2:00 P.M., and 10:00 P.M.; and 03/01/26 at 6:00 A.M. and 2:00 P.M. were missed. Nurse progress notes from 02/27/26 to 03/02/26 contained no documentation that the physician was notified of the missed cefazolin doses and no documentation of contact with the pharmacy regarding delivery of the medication. The pharmacist confirmed that cefazolin for this resident was delivered on 03/01/26 at 12:49 P.M., and the DON confirmed that the resident had six missed doses and that the medical record lacked documentation of physician notification or pharmacy contact. Facility policy titled “Administering Medications” dated April 2019 required medications to be administered in a safe and timely manner and as prescribed. The identified deficiency was investigated under Complaint Number 2801711.
Medication Administration Errors Due to Unavailable Medications
Penalty
Summary
The facility failed to administer medications as ordered by physicians, resulting in four medication errors out of 41 opportunities, which equates to a 9.75% medication error rate. This deficiency affected three residents who were observed during medication administration. Specifically, one resident with diagnoses including left ventricular failure and cognitive communication deficit did not receive prescribed Potassium and Buprenorphine due to the medications not being available. Another resident with epilepsy, COPD, and anxiety disorder did not receive their ordered Zoloft, and a third resident with atherosclerotic heart disease, diabetes, and convulsions did not receive their prescribed Levetiracetam, both omissions also due to the medications not being available at the time of administration. Observations and staff interviews confirmed that the medications were omitted during the morning medication pass because they were not on hand. Review of facility policy indicated that medications should be reordered from the pharmacy at least three days before the last dose is administered to ensure availability. The failure to have these medications available and administered as ordered led directly to the cited deficiency.
Failure to Complete Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to ensure Certified Nursing Assistants received annual performance evaluations, based on personnel record review, staff interview, and review of the facility policy. Review of CNA #213’s personnel file showed a hire date of 03/27/23 with no performance evaluations from 03/27/24 through 08/07/25. Review of CNA #224’s personnel file showed a hire date of 08/29/23 with no performance evaluations from 08/29/23 through 08/07/25. During an interview on 08/07/25 at 8:47 A.M., Human Resources #202 verified that the facility had not completed annual performance evaluations for CNAs #213 and #224. The facility policy titled Performance Evaluations, dated September 2020, stated that the job performance of each employee should be reviewed and evaluated at least annually.
TB Screening and Medication Handling Deficiencies
Penalty
Summary
The facility failed to implement its tuberculosis (TB) control plan for newly hired employees. Review of personnel records showed that CNA #213, CNA #110, LPN #227, Housekeeper #247, and Admissions Director #201 each had a hire date documented, but none had a two-step TB skin test upon hire. During interview, Human Resources #202 confirmed the facility had not conducted a TB skin test upon hire for these employees and stated that a two-step TB skin test should be completed when employees are hired. The facility policy titled Employee Screening for Tuberculosis, dated July 2010, stated that all employees should be screened for TB infection and disease using a two-step TB skin test. The facility also failed to ensure staff practiced appropriate hand hygiene during medication administration. During observation of medication pass to Residents #11, #36, #47, and #41, RN #258 placed the residents’ medications into medication cups using bare hands. In interview, RN #258 confirmed she had touched the medications with her bare hands prior to administration. The facility policy titled Administering Oral Medications, dated October 2010, stated that staff members should not touch residents’ medications with ungloved hands.
Missing Annual CNA In-Service Training
Penalty
Summary
The facility failed to ensure Certified Nursing Assistants (CNAs) received at least 12 hours of annual in-service education. Review of personnel records showed CNA #209, hired 05/20/80, had no documented in-service education from 05/20/24 to 08/07/25; CNA #213, hired 03/27/23, had no documented in-service education from 03/27/24 to 08/07/25; and CNA #224, hired 08/29/13, had no documented in-service education from 08/29/23 to 08/07/25. During an interview on 08/07/25 at 8:47 A.M., HR #202 confirmed the facility did not have documentation of 12 hours of annual in-service education for these CNAs. The facility policy titled In-Service Training stated that all CNAs employed by the facility must complete a minimum of 12 hours of in-service training annually.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegations
Penalty
Summary
The facility failed to report allegations of resident-to-resident sexual abuse to the state agency within the required 24-hour timeframe. This deficiency was identified through medical record reviews, facility self-reported incidents (SRIs), incident investigations, and interviews with residents and staff. In one instance, a resident with severe cognitive impairment and another resident with moderate cognitive impairment were observed in a sexually inappropriate situation. Staff separated the residents and documented the event, but the incident was not reported to administration or the state agency until several days later. The Director of Nursing (DON) confirmed that the staff did not immediately report the incident, and the SRI was filed four days after the event occurred. In another case, two residents were observed engaging in sexual activity in a public area of the facility, specifically the smoking porch, in the presence of other residents. Both residents were physically exposed, and other residents complained about the incident. Staff addressed the behavior with the involved residents, but the incident was not reported to the administration or the state agency as required. The DON later confirmed that the incident was not investigated promptly to determine if sexual abuse had occurred, and the facility did not immediately file an SRI. The facility's policy required all allegations of abuse to be reported within the required timeframes, but this was not followed. Interviews with staff, including an LPN and a CNA, confirmed that the incidents were observed and reported internally but not escalated to the appropriate administrative or regulatory authorities in a timely manner. The DON and Administrator acknowledged the delay in reporting and the lack of immediate investigation. The failure to report these incidents as required affected four residents reviewed for abuse, all of whom had varying degrees of cognitive and behavioral impairments.
Failure to Timely and Thoroughly Investigate Resident-to-Resident Sexual Abuse Allegations
Penalty
Summary
The facility failed to thoroughly and timely investigate multiple allegations of resident-to-resident sexual abuse, affecting four residents. In one incident, a resident with severe cognitive impairment and a history of sexually inappropriate behavior was observed sitting on another resident's lap and kissing him. Staff separated the residents and provided education on personal boundaries, but the incident was not immediately reported to administration. The Director of Nursing (DON) only became aware of the event two days later during a routine review, and the state-required Self-Reported Incident (SRI) was not filed until four days after the incident. The facility's investigation did not include timely interviews or witness statements from staff involved, and the residents involved did not recall the incident when later interviewed. In another event, two residents were observed engaging in sexual activity in a public area, specifically the smoking porch, in view of other residents. Staff intervened and explained the inappropriateness of the behavior, but the residents dismissed the staff's concerns. Despite the incident being reported to the DON the following day, no investigation was initiated until several weeks later. The facility did not immediately assess the residents' capacity to consent or report the incident to the state agency as required. The DON later confirmed that the decision not to file an SRI was based on an assumption of consent, without proper investigation. The facility's policy required immediate investigation and thorough documentation of all abuse allegations, including identification of responsible staff, interviews with all involved parties, and a focus on determining the occurrence and extent of abuse. However, in both incidents, the facility failed to follow these procedures, resulting in delayed and incomplete investigations. The lack of timely reporting, failure to obtain staff and witness statements, and inadequate assessment of resident capacity to consent contributed to the deficiency.
Failure to Provide Hand and Nail Hygiene for Dependent Resident
Penalty
Summary
The facility failed to provide appropriate hand and nail hygiene for a dependent resident who required staff assistance with personal care. Medical record review showed the resident had moderately impaired cognition and required help with bathing and personal hygiene. During observation, the resident was found to have fingernails that were too long and had debris underneath, which interfered with his ability to use his communication device. The resident confirmed that staff had not offered to cut his nails, and the length of his nails made it difficult for him to use his iPad for communication. Interviews with facility staff, including the DON, ADON, and an LPN, confirmed that nail care was expected to be performed during scheduled showers, which were offered at least twice weekly, but there was no set schedule for hand or nail care outside of these times. The facility policy required daily cleaning and regular trimming of nails, but this was not consistently implemented. Staff also confirmed that documentation of nail care or refusals was expected but not always completed. This resulted in the resident not receiving necessary nail care as required by facility policy.
Failure to Implement Physician-Ordered Fall Prevention Intervention
Penalty
Summary
A deficiency occurred when the facility failed to implement fall prevention interventions as ordered by the physician and outlined in the resident's care plan. A resident with diagnoses including type two diabetes mellitus, chronic kidney disease, depression, and spastic hemiplegia was identified as being at risk for falls, with a history of one to two falls in the past three months. The care plan and physician's order specified that a fall mat should be placed on the right side of the resident's bed at all times when the resident was in bed, following a recent fall where the resident rolled out of bed while attempting to reposition himself. Despite these documented interventions, multiple observations on consecutive days revealed that the fall mat was not in place while the resident was in bed. Staff interviews with CNAs and an LPN confirmed that the fall mat was not present, even though they were aware of the care plan and physician's order. Review of the facility's policy on managing falls indicated that staff were expected to implement interventions to prevent falls and minimize complications, but this was not followed in this instance.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to notify the Ombudsman’s office of a resident’s hospitalization and discharge from the facility. Resident #56 was admitted on 02/28/25 with diagnoses including encephalopathy, opioid use, and chronic viral hepatitis C, and was discharged on 03/20/25. The MDS assessment dated 02/28/25 showed the resident was cognitively intact and required staff assistance with ADLs. Review of the medical record did not include documentation that the Ombudsman was notified of the resident’s hospitalization and discharge, and the Administrator confirmed in interview that the facility did not notify the Ombudsman of the discharge. Facility policy titled Transfer or Discharge, Facility-Initiated, dated October 2022, stated the facility was to provide notice of transfer to the long term care Ombudsman as soon as practicable.
Inaccurate MDS Coding for Falls and Left-Hand Contracture
Penalty
Summary
The facility failed to ensure Resident #31’s MDS assessments were accurately coded for falls and contractures. Resident #31 was admitted on 04/07/25 with diagnoses including type two diabetes mellitus, chronic kidney disease, depression, and spastic hemiplegia. The record showed multiple falls during the stay, including a fall near the bed on 04/10/25 after the resident attempted to self-transfer to a wheelchair, a fall in the bathroom on 04/15/25 while trying to use the toilet, an unwitnessed fall in the shower room on 06/01/25, and an unwitnessed fall out of bed on 07/10/25 that resulted in a skin tear. However, the 04/14/25 MDS stated the resident had no falls since admission, and the 07/15/25 MDS stated the resident had only one fall with injury since the prior assessment. The record also showed the resident had a left-hand deformity/contracture that was present throughout the stay. On 08/04/25, observation showed the resident’s left hand second digit crossed over the third digit and the resident could not extend the third and fourth digits. The resident stated the left hand injury occurred before admission and had caused a contracture during the entire stay. The DON confirmed the resident had a previous hand fracture that caused a hand deformity and that the facility had no documentation of the prior hand injury or a care plan for the left-hand deformity. The DOT verified the resident had a partial contracture of the left hand and confirmed there were no documented therapy notes, assessments, or recommendations for the contracture. MDS LPN #260 confirmed the 04/14/25 and 07/15/25 MDS assessments were not correctly coded for falls and contracture, and the facility policy required the person completing the MDS portion to certify its accuracy.
PASARR Screening Incomplete for a Resident with Schizoaffective Disorder
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not accurately completed for a newly admitted resident. The resident was admitted with diagnoses including radiculopathy, schizoaffective disorder, bipolar disorder, and congestive heart failure. The MDS assessment later showed the resident was moderately cognitively impaired and required staff assistance with ADLs. Review of the PASARR dated 01/17/25 showed that the resident’s schizoaffective disorder diagnosis was not included on the PASARR. The Administrator and the Social Services Designee both verified that the schizoaffective disorder diagnosis was not listed or marked on the PASARR.
Failure to Care Plan Left Hand Contracture
Penalty
Summary
The facility failed to develop a care plan for a resident's left hand contracture. The resident was admitted with diagnoses including type 2 diabetes mellitus, chronic kidney disease, depression, and spastic hemiplegia, and the care plan initiated on admission did not include any plan for the hand contracture. The resident later had MDS assessments that indicated no upper extremity impairment affecting daily function or placing the resident at risk for injury, and the MDS LPN confirmed those assessments were not correctly coded regarding the left-hand contracture. Observation showed the resident's left hand second digit crossed over the third digit, and the resident was unable to extend the third and fourth digits. The resident stated the left hand injury occurred before admission and had caused a contracture that had been present throughout the stay. The DON confirmed the resident had a previous hand fracture that caused a hand deformity and verified the facility had no documentation of the prior hand injury and no care plan for the left-hand deformity. The DOT also confirmed the resident had a partial contracture of the left hand and that the facility had no documented therapy notes, assessments, or recommendations for the condition.
Smoking Care Plans Not Updated
Penalty
Summary
The facility failed to update care plans for residents who smoked cigarettes, affecting two of four residents reviewed for smoking. Resident #21 was admitted with diagnoses including multiple sclerosis, subdural hematoma, anxiety disorder, anti-social disorder, and spondylosis. His MDS showed he was cognitively intact and required supervision with ADLs. The smoking assessment dated 10/27/24 had a box checked indicating supervision during smoking times, but it was unscored and did not clearly identify whether he was an independent or supervised smoker. The care plan dated 11/26/24 stated he was to be supervised during smoking times, while the resident stated he had no set smoking times, smoked on the patio at will, and managed his own cigarettes and lighters. The AD confirmed the facility considered him an independent smoker, but his care plan had not been updated to reflect that status. Resident #18 was admitted with diagnoses including COPD and acute respiratory failure. The smoking assessment dated 06/26/25 was unscored and did not clearly indicate whether the resident was an independent or supervised smoker. The care plan identified a risk of complication/injuries related to tobacco use and a preference to smoke cigarettes, with the only intervention being staff assistance to smoking areas as needed. The MDS dated 07/02/25 showed mild cognitive impairment. The AD confirmed the resident was on oxygen and needed staff assistance to remove tubing before smoking, light cigarettes, and hold the cigarettes because of a hand tremor, but the smoking care plan had not been updated with interventions for safe smoking. The facility policy stated residents would be assessed for their ability to smoke safely and that this information would be included in the care plan.
Failure to Address Resident Hand Contracture
Penalty
Summary
The facility failed to provide treatment for a resident’s hand contracture. Resident #31 was admitted with diagnoses including type 2 diabetes mellitus, chronic kidney disease, depression, and spastic hemiplegia. The care plan initiated on 04/07/25 did not include a care plan for hand contractures, and the MDS assessments dated 04/14/25 and 07/15/25 both indicated no upper extremity impairment that interfered with daily functions or placed the resident at risk for injury. During observation on 08/04/25, the resident’s left hand second digit was crossed over the third digit, and the resident was not able to extend the third and fourth digits. The resident stated he had sustained an injury to his left hand prior to admission that caused a contracture present throughout his stay. The DON confirmed the facility had no documentation of the prior hand injury and no care plan for the left hand deformity. The DOT confirmed the resident had a partial contracture of the left hand and that there were no documented therapy notes, assessments, or recommendations for the contracture. The MDS LPN confirmed the MDS assessments were not correctly coded regarding the resident’s left-hand contracture.
Improper Labeling of Insulin Pens
Penalty
Summary
Drugs and biologicals were not labeled in accordance with accepted professional principles because insulin pens were found in medication carts without the required resident identification and/or open dates. During observation of medication cart #3, surveyors found an unlabeled insulin pen with an open date. The Assistant Director of Nursing confirmed the unlabeled pen in the cart. During observation of medication cart #2, surveyors found an open Lantus insulin pen for Resident #4 without an open date, an open Humalog insulin pen for Resident #51 with an open date, and a Lantus insulin pen for Resident #38 without an open date. The ADON confirmed these findings during interview. The facility policy stated that multi-dose medications are to be labeled with an open date and insulin pens are to be labeled with the corresponding resident's name.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment, affecting 36 residents out of a census of 45. During an initial tour, it was observed that a resident's room had dirty linen spread across the floor, walls with large areas needing repair, a stained and sticky floor tile, a wall shelf removed and leaning in a corner, and a small closet lacking cove base. Additionally, the main corridor had five light fixtures without covers, exposing the bulb and wiring, and the handrails lacked endcaps. These conditions were verified by the Administrator and Maintenance Director. The resident involved, who had diagnoses of thoracic spinal fracture with paraplegia, protein-calorie malnutrition, and schizophrenia, expressed dissatisfaction with the state of her room, particularly the walls, floor, and closet. The facility's policy on providing a safe, clean, comfortable, and homelike environment was not adhered to, as evidenced by the observations and interviews conducted. This deficiency was investigated under Complaint Number OH00162166.
Dishwasher Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its dishwasher in a manner that prevents foodborne illness, affecting all 46 residents who received food from the kitchen. During an observation of the facility's kitchen, it was noted that the dishwasher had a wash and rinse temperature of 120 degrees Fahrenheit. The Dietary Manager (DM) tested the chemical sanitizer in the dishwasher, which registered at zero parts per million (ppm). The DM confirmed that the dishwasher was a low-temperature model requiring chemical sanitization, and verified that it was operating without the necessary chemical sanitizer. This deficiency was investigated under Complaint Number OH00161042.
Failure to Notify State Mental Health Authority of Significant Changes
Penalty
Summary
The facility failed to notify the state mental health authority of significant changes in the mental health conditions of two residents, as required by the Pre-Admission Screening and Resident Review (PASARR) process. Resident #19, who was admitted with various medical conditions including opioid dependence, received a new diagnosis of adjustment disorder on September 19, 2023. However, the facility did not complete a significant change PASARR or notify the state mental health authority of this new diagnosis. This oversight was confirmed during an interview with the Social Services Director on January 9, 2025. Similarly, Resident #46, admitted with multiple diagnoses including alcohol abuse with withdrawal, was diagnosed with depression on June 2, 2023. The facility again failed to complete a significant change PASARR or notify the state mental health authority of this new diagnosis. This was also confirmed during the same interview with the Social Services Director. The facility's PASRR policy, dated April 1, 2023, mandates compliance with the Ohio Department of Medicaid regulations, which the facility did not adhere to in these cases.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, addressing their specific medical and personal needs. Resident #28, who was admitted with multiple diagnoses including necrotizing fasciitis and type two diabetes mellitus, did not have a care plan to address his dental needs despite being edentulous and scheduled for dental impressions for dentures. The MDS Coordinator confirmed the absence of a dental care plan for Resident #28, despite the resident's cognitive intactness and the facility's awareness of his dental status. Similarly, Resident #19, who had a below-the-knee amputation and was cognitively intact, lacked a care plan for his prosthetic limb and activities. Despite having received a prosthetic limb and being involved in therapy, there was no care plan to address his amputation or prosthetic use. The resident reported participating in therapy and occasional facility activities but preferred staying in his room. The MDS Coordinator verified the absence of care plans for Resident #19's prosthetic limb and activities, indicating a failure to meet the facility's care planning policy.
Failure to Address Prosthetic Limb Issues Timely
Penalty
Summary
The facility failed to address a resident's issues with a prosthetic limb in a timely manner, affecting one of two residents with prostheses. The resident, who had a below-the-knee amputation, was admitted with multiple diagnoses including severe protein calorie malnutrition, type two diabetes mellitus, and opioid dependence. The resident received a prosthesis on April 25, 2024, but experienced discomfort and fitting issues, which were not promptly resolved. The resident's physical therapy notes indicated ongoing problems with the prosthesis, including discomfort and pain, leading to the resident's inability to tolerate wearing it. Despite being instructed to contact the prosthetic company for adjustments, the resident continued to experience issues. The resident was discharged from physical therapy on May 30, 2024, due to meeting the highest practical level of achievement, yet still could not use the prosthesis effectively. Occupational therapy also noted non-compliance with the treatment plan, further complicating the situation. The Director of Rehabilitation, who started in September 2024, discovered that the resident's insurance had not been billed for the original prosthesis, and the prosthesis was returned due to its poor fit. The resident had a lump on the limb that was not accommodated by the prosthesis, and the straps caused skin irritation. The facility's failure to follow up on the prosthesis from May 30, 2024, to September 10, 2024, contributed to the deficiency, as the resident remained without a properly fitting prosthesis for an extended period.
Failure to Report Misappropriation of Resident Funds
Penalty
Summary
The facility failed to report an allegation of misappropriation of resident funds to the Ohio Department of Health (ODH), affecting one resident out of three reviewed for such issues. The resident involved, identified as Resident #33, had intact cognition and required supervision with activities of daily living. On a specific date, the resident reported to a Licensed Practical Nurse (LPN) that two hundred dollars had been stolen from his room. The LPN documented the allegation and indicated it would be reported to the administration. Despite the report made by the LPN, the facility did not complete a Self-Reported Incident (SRI) regarding the allegation. Interviews with the Director of Nursing (DON) and the Administrator confirmed that the allegation was known to the staff but was not reported to the ODH as required. The facility's policy on abuse, neglect, exploitation, and misappropriation prevention mandates that such allegations be investigated and reported within the timeframes required by federal regulations. This deficiency was investigated under a specific complaint number.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain medication error rates below five percent, resulting in an observed error rate of 11.1% based on 36 medication opportunities and four observed errors. This deficiency affected three residents. Resident #21, diagnosed with bipolar disorder, congestive heart failure, and type two diabetes mellitus, did not receive loratadine due to its unavailability and was administered Lantus insulin without priming the pen, contrary to the manufacturer's instructions. LPN #20 confirmed these errors during an interview. Resident #26, with diagnoses including type two diabetes mellitus and chronic kidney disease, did not receive amiodarone as it was unavailable. Similarly, Resident #27, diagnosed with emphysema and generalized anxiety disorder, did not receive Claritin due to its unavailability. The facility's policy mandates that medications be administered safely, timely, and as prescribed, which was not adhered to in these instances. This deficiency was investigated under Complaint Number OH00157751.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to ensure a clean, safe, and comfortable environment for all 46 residents, as evidenced by multiple observations and interviews. The lower level, which is frequently used by residents for therapy and activities, was found to be inadequately lit, with broken and discolored ceiling tiles, cobwebs, dust, debris, and dead bugs throughout the area. A ceiling light cover was hanging down with exposed wires, and the exit enclosure was cluttered with cobwebs, dirt, and broken windows. Additionally, there was an unsecured storage area with broken fixtures and exposed pipes, and a broken electric steam table was left in the open. The 200-hall, where several residents' rooms are located, had dead bugs in light fixtures, missing light covers, and lacked handrails. The shower/bathroom in this hall had broken tiles, standing water, mold-like discoloration, rusted grab bars, and broken mirrors. Residents' windows were heavily damaged from water leaks, requiring towels to soak up rainwater. Interviews with residents confirmed the persistent water leakage and damage, with some residents having to move their beds away from the walls to avoid water damage. The 100-hall and dining room also exhibited multiple deficiencies, including mismatched paint, holes in walls, discolored and missing ceiling tiles, and dusty air vents. The kitchen area had missing ceiling tiles and dead bugs in light fixtures above food preparation areas. The 300-hall, a secured behavior unit, had similar issues with broken tiles, mold-like discoloration, and non-functional hot water in the handwashing area. Interviews with staff and residents corroborated these findings, highlighting the facility's ongoing issues with maintenance and cleanliness.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, which had the potential to affect all 46 residents. During an observation of the kitchen, it was noted that the trash cans had a build-up of food debris and splatter on the sides and lacked lids. Additionally, the wall tiles near the three-compartment sink were covered with an unknown black substance resembling mold. These findings were confirmed by the Dietary Manager present during the observation. Further observation of the tray service line revealed that a dietary staff member did not sanitize the food thermometer before or between taking temperatures of different food items. The thermometer was used consecutively on broccoli, pork stir fry, hamburger patty, and rice without any sanitization. The facility's policy on sanitation, dated June 2016, requires dietary staff to maintain sanitation through a comprehensive cleaning schedule, which was not followed in this instance.
Equipment Maintenance Failures in LTC Facility
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition, affecting two residents and potentially all 46 residents due to a malfunctioning dishwasher. Resident #24's bed was broken, with the bottom frame twisted and the mattress not properly aligned, causing discomfort and potential safety issues. Despite attempts by a State Tested Nurse Aide (STNA) to fix the bed, the problem persisted, indicating a lack of timely maintenance and repair. Resident #27's bed had a spliced electrical cord, joined with wire nuts and electrical tape, and was plugged into a damaged outlet. This makeshift repair was done by the Maintenance Supervisor, who claimed it was a temporary fix until a new cord could be ordered. The bed's malfunction prevented it from moving up and down, which was necessary for providing personal care. The resident was unaware of the unsafe condition of the bed's electrical cord. The facility's dishwasher was also not maintained properly, with a non-functional thermostat gauge and failure to reach the required sanitization temperature of 120 degrees Fahrenheit. The Dietary Manager used a food thermometer to check temperatures, which consistently fell short. Additionally, the sanitizer was not being dispensed due to worn-out parts, and temporary fixes were not effective. The facility lacked documentation of ordered parts or routine maintenance records, and the local Health Department had previously noted issues with sanitizer concentration monitoring.
Lack of Secured Handrails in 200 Unit Hallway
Penalty
Summary
The facility failed to ensure that there were secured handrails throughout the hallway on the 200 unit, which had the potential to affect 15 independently mobile residents residing in that unit. During an initial tour of the 200-hall, it was observed that there were no handrails affixed to the walls. This observation was confirmed in an interview with the Administrator, who acknowledged the absence of handrails and mentioned that the unit was undergoing remodeling, and he would need to order them. This deficiency was investigated under Master Complaint Numbers OH00156054, OH00155202, and OH00155184.
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What surveyors actually found near you
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Cincinnati
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Astoria Place Of Cincinnati | 0.2 mi | ★★★★★ | 42 | 0 |
| Lincoln Crawford Care Center | 1.3 mi | ★★★★★ | 7 | 0 |
| Norwood Towers Post-acute | 1.6 mi | ★★★★★ | 30 | 0 |
| Scarlet Oaks Nursing And Rehabilitation Center | 1.6 mi | ★★★★★ | 0 | 0 |
| Seven Acres Senior Living At Clifton | 1.7 mi | ★★★★★ | 1 | 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.