Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Grafton Oaks Nursing Center during CMS and state inspections, most recent first.
The facility failed to include non-invasive mechanical ventilator (BiPAP) use in the comprehensive care plans for two residents with chronic respiratory conditions and sleep apnea, despite active physician orders and MDS assessments documenting BiPAP use. Both residents had BiPAP orders for nightly use, and one also had orders for use as needed during daytime sleep, yet their care plans contained no BiPAP-related problems, goals, or interventions. The MDS nurse, responsible for nursing care plans, acknowledged the omissions, while the DON and Administrator stated they expected BiPAP to be addressed in the care plans, consistent with facility policy requiring comprehensive, measurable, person-centered care plans that include all services identified in the assessment.
Failure to Complete Baseline Care Plan After Admission: A resident admitted with COPD, type II diabetes, and respiratory disorders did not have a baseline care plan completed within the required 48 hours. An LPN, RN, MDS nurse, ADON, DON, and Administrator all confirmed the plan was missing or overdue, and the ADON stated she was the admitting nurse responsible for the omission.
A resident with CHF, cardiomyopathy, HTN, and SVT had a 2,000 ml fluid restriction, but the care plan, order summary, and MAR did not specify how fluids were to be divided between dietary and nursing. An LPN was unaware of the restriction, the MAR had no place to document fluids consumed, and staff interviews showed the DT was responsible for entering the breakdown but did not do so, so the fluid restriction was not reflected for nursing documentation.
A resident with COPD, chronic respiratory failure, and OSA had an active BiPAP order, but staff observed the BiPAP mask uncovered on the bedside table and later on the floor at the head of the bed when it was not in use. An LPN confirmed the mask should be stored in a plastic bag, and the DON and Administrator stated BiPAP equipment was expected to be cleaned and stored in a bag or covered for sanitation purposes; the facility policy called for clean, dry equipment to be kept in a labeled, breathable container away from contaminated surfaces.
Medication Error Rate Exceeded 5 Percent: Surveyors found a 16% medication error rate after observing four errors in 25 opportunities. An RN crushed enteric coated aspirin and potassium chloride for one resident and crushed enteric coated aspirin for another, despite package directions not to crush those medications. An LPN also gave Senna Plus instead of the ordered senna tablet to a resident with constipation. The DON and Administrator stated the expected medication error rate was less than 5%.
Failure to Transcribe BiPAP Cleaning Order to MAR/TAR: A resident with COPD, chronic respiratory failure, and OSA had an active order for daily BiPAP mask cleaning, but the MAR/TAR showed no transcription of that order. Staff interviews confirmed nurses were responsible for the task and that physician orders should have been entered into the MAR or TAR.
Nonfunctioning Wheelchair Brake Not Maintained: A resident with CVA, gait/mobility impairment, and polyarthritis used a wheelchair with a left brake handle that was dangling and non-functioning. The resident said the brake had been broken for months and that they used their bare hand to stop the wheelchair from moving. A CNA said the issue had been known since 11/2025 and that a work order had been submitted, but records showed no work order. The current Maintenance Director said he was unaware of the problem until notified by the DON, while the facility policy stated hazardous safety concerns are urgent and should be addressed the same day when possible.
A cognitively impaired resident was sexually abused by another resident who entered her room and engaged in inappropriate contact, while two staff members witnessed the event but did not intervene. The abused resident, due to severe cognitive impairment, was unable to recall the incident, and the facility failed to ensure her protection as required by policy.
A resident's medication card, which included protected health information, was mistakenly given to another resident at discharge. The error was identified when the receiving resident's family contacted the facility about the mix-up, confirming that the facility did not maintain the confidentiality of the resident's health information as required by policy.
Failure to Include BiPAP Use in Comprehensive Care Plans for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive care plans that addressed the use of non-invasive mechanical ventilators (BiPAP) for two residents with chronic respiratory conditions. One resident had diagnoses including COPD, chronic respiratory failure, and obstructive sleep apnea, with an active order for auto BiPAP every night at bedtime and as needed during daytime sleep. A quarterly MDS showed moderately impaired cognitive skills and documented use of a non-invasive mechanical ventilator in the 14-day look-back period. Despite this, the resident’s comprehensive care plan, in place since admission, did not address BiPAP use, even though surveyors observed a BiPAP machine in the resident’s room on multiple occasions. The MDS nurse, responsible for nursing care plans, confirmed during interview that there was no BiPAP care plan and stated the resident should have one so staff would know about the BiPAP. The second resident had chronic respiratory failure and obstructive sleep apnea, with an order to wear BiPAP at night for sleep apnea and an admission MDS indicating intact cognition and use of a non-invasive mechanical ventilator in the last 14 days of the assessment period. Review of this resident’s comprehensive care plan, initiated at admission, also showed no care plan or interventions related to BiPAP use. The MDS nurse acknowledged the absence of BiPAP-related interventions in this care plan. The DON and the Administrator both stated in interviews that they expected BiPAP use to be addressed on residents’ comprehensive care plans, and the facility’s Comprehensive Care Plans policy required development of person-centered care plans with measurable objectives and timeframes that include all services identified in the comprehensive assessment and meeting professional standards of quality.
Failure to Complete Baseline Care Plan After Admission
Penalty
Summary
The facility failed to develop a baseline care plan for Resident #91 within 48 hours of admission. Resident #91 was admitted with diagnoses including chronic obstructive pulmonary disease, type II diabetes, and respiratory disorders, and the medical record review found no evidence of a baseline care plan for the resident. During interviews, LPN #6 stated a baseline care plan should be completed upon admission and was unable to locate one for Resident #91. RN #3 confirmed the resident did not have a baseline care plan. The MDS Nurse stated the admitting nurse was responsible for completing the baseline care plan during admission and that it was needed to guide staff and ensure proper care, and confirmed it was overdue. The ADON, who was the admitting nurse for Resident #91, stated she did not implement the required baseline care plan and described the omission. The DON stated the facility had 48 hours to complete a baseline care plan after admission and that the admitting nurse was responsible for it, while the Administrator stated the plan was to be developed before the comprehensive care plan and confirmed the facility failed to complete Resident #91's baseline care plan timely.
Fluid Restriction Order Not Broken Down Between Dietary and Nursing
Penalty
Summary
The facility failed to specify the breakdown of a 2,000 ml fluid restriction between the food and nutrition department and the nursing department for Resident #40. The resident was admitted with diagnoses including supraventricular tachycardia, systolic congestive heart failure, cardiomyopathy, and hypertension. The Care Plan Report and the Order Summary Report both showed the 2,000 ml fluid restriction, but neither included the amount of fluid to be provided by dietary and nursing. The resident’s MARs for 11/2025, 12/2025, and 01/2026 also showed no evidence that staff monitored the fluids offered and/or consumed by the resident. During observation, Resident #40 had fluids present on the breakfast tray and a water pitcher on the overbed table, and an LPN stated the resident consumed water with morning medication administration. The LPN stated she was not aware of the fluid restriction order and confirmed the MAR did not record the amount of fluids nursing staff could provide and had no place to document fluids consumed. Staff interviews showed the LPN Case Manager and DT stated the DT was responsible for calculating and entering the fluid breakdown for nursing and dietary, and the RD stated the DT was responsible to divide fluids between the departments and relay the information. The DT reviewed the record and confirmed she did not break down the fluid order, so it did not appear on the MAR for nursing to record fluids received each shift. The facility policy required the physician’s order to include the breakdown of fluid amounts per 24 hours between the food and nutrition department and the nursing department and for it to be recorded on the MAR or other facility format.
BiPAP Mask Not Stored Properly When Not in Use
Penalty
Summary
The facility failed to ensure a BiPAP mask was stored properly when not in use for one resident. The resident was admitted with chronic obstructive pulmonary disease, chronic respiratory failure, and obstructive sleep apnea, and the quarterly MDS indicated moderately impaired cognitive skills for daily decision-making and use of a non-invasive mechanical ventilator during the assessment period. The resident had an active order for auto BiPAP every night at bedtime and as needed throughout the day during sleep. During observation, the resident’s BiPAP mask was seen attached to the machine on the bedside table and uncovered, and later it was observed on the floor at the head of the bed. An LPN stated the mask should be stored in a plastic bag when not in use and verified it was not where it should be stored. The DON stated that if the BiPAP mask was not on the resident, it should be stored in a bag after being wiped down, and the Administrator stated BiPAP masks were expected to be cleaned and stored in a bag or covered for sanitation purposes. The facility policy for CPAP/BiPAP therapy stated clean, dry equipment should be stored in a labeled, breathable container and kept away from sinks, toilets, and contaminated surfaces.
Medication Error Rate Exceeded 5 Percent
Penalty
Summary
The facility failed to ensure its medication error rate remained below 5 percent. Surveyors identified four medication errors out of 25 opportunities, resulting in a 16% error rate and affecting three residents observed during medication administration. The facility’s own DON and Administrator both stated their expectation was for the medication error rate to be less than 5%, and the facility policy required medications to be administered as ordered by the physician and in accordance with professional standards of practice. For one resident with chronic embolism and thrombosis of both lower extremities and stage II chronic kidney disease, RN #3 crushed enteric coated aspirin 81 mg and potassium chloride 10 mEq before giving the medications in pudding, despite package inserts stating the aspirin should not be crushed and the potassium chloride should be taken without crushing, chewing, or sucking. For another resident with cerebral infarction and acute ischemic heart disease, RN #3 crushed enteric coated aspirin 81 mg before administration, even though the package insert stated not to chew, crush, or cut the medication. For a third resident with constipation, an LPN administered Senna Plus instead of the ordered senna 8.6 mg tablet and confirmed the medication was not the same as the physician-ordered drug.
Failure to Transcribe BiPAP Cleaning Order to MAR/TAR
Penalty
Summary
The facility failed to ensure Resident #69’s physician order was transcribed to the MAR/TAR. Resident #69 was admitted with diagnoses including chronic obstructive pulmonary disease, chronic respiratory failure, and obstructive sleep apnea. The quarterly MDS indicated the resident had moderately impaired cognitive skills for daily decision-making and used a non-invasive mechanical ventilator during the last 14 days of the assessment period. The resident’s Order Summary Report showed an active order dated 09/18/25 directing staff to clean the resident’s BiPAP mask daily with warm soapy water and allow it to air dry every day shift. However, the MAR and TAR for 01/01/26 through 01/31/26 contained no evidence that this order had been transcribed. During interviews, an LPN stated nurses were responsible for cleaning the BiPAP mask, another LPN stated the cleaning was signed off on the TAR by the nurse who completed it, and the DON and Administrator stated physician orders should be transcribed into the MAR or TAR by nursing staff.
Nonfunctioning Wheelchair Brake Not Maintained
Penalty
Summary
The facility failed to keep a resident’s wheelchair brake in safe and functional condition for one resident who had a history of cerebral infarction affecting the right dominant side, gait and mobility abnormalities, and polyarthritis. The resident’s quarterly MDS showed intact cognition and wheelchair use. During observation and interview, the resident’s left wheelchair brake handle was dangling from the seating bar and was non-functioning, and the resident stated the brake had been broken for a few months. The resident also stated they had been using their bare hand to stop the wheelchair from moving forward and that the former Maintenance Director had been told about the broken brake and that replacement parts would be ordered. A CNA confirmed she had been informed of the broken brake handle and stated it had been broken since 11/2025, with the former Maintenance Director aware of the issue. She also stated a work order had been submitted and that the facility was waiting for parts, but the facility records contained no evidence of a work order for the wheelchair brake handle. The current Maintenance Director stated he was unaware of the broken brake until notified by the DON, and said the former Maintenance Director had been informed but the issue had not been resolved. The Administrator stated it was her expectation that staff inform maintenance or management of resident issues. The facility policy stated hazardous and safety concerns are considered urgent and, when possible, addressed the same day.
Failure to Protect Cognitively Impaired Resident from Sexual Abuse
Penalty
Summary
A severely cognitively impaired resident with diagnoses including schizophrenia, bipolar disorder, diabetes, anxiety disorder, and dementia was sexually abused by another resident. The incident occurred when a male resident, who was cognitively intact and ambulatory with a walker, entered the female resident's room, lifted her top, and touched and sucked on her breasts. The female resident was lying in bed, did not move or resist, and later could not recall the incident when questioned by staff and law enforcement. The male resident stated he believed the contact was consensual and that he was trying to make friends with the female resident. Two housekeepers witnessed the male resident engaging in the inappropriate sexual contact but did not intervene to stop the abuse. Instead, one housekeeper remained in the room while the other sought assistance. By the time a registered nurse arrived, the male resident had ceased the contact, adjusted the female resident's clothing, and left the room. The nurse assessed the female resident and found no injuries or signs of distress, and the incident was reported to facility administration and local law enforcement. The facility's policy stated that residents should be protected from sexual abuse and that steps should be taken if a resident might lack the capacity to consent to sexual activity. Despite this, the staff failed to prevent or immediately stop the abuse, resulting in actual harm to the cognitively impaired resident. The incident was substantiated by witness statements, medical assessments, and interviews with both residents and law enforcement.
Failure to Maintain Resident Health Information Confidentiality
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's protected health information when a medication card containing private medical details was given to another resident at discharge. Specifically, a resident with diagnoses including acute myeloblastic leukemia, type two diabetes mellitus, atherosclerotic heart disease, and hypertension, who had moderately impaired cognition and required staff assistance with activities of daily living, was discharged, and their medication card for Lasix 40 mg was mistakenly sent home with another resident. The error was discovered when the receiving resident's family notified the facility about the medication mix-up. The facility's policy required the protection of resident health information, but this policy was not followed in this instance.
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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 Dayton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Gem City Healthcare And Rehabilitation Center | 0.3 mi | ★★★★★ | 9 | 0 |
| Dunbar Health & Rehab Center | 1.6 mi | ★★★★★ | 0 | 0 |
| Carecore At Mary Scott | 1.7 mi | ★★★★★ | 24 | 0 |
| Riverside Nursing And Rehabilitation Center | 2.7 mi | ★★★★★ | 21 | 1 |
| Widows Home Of Dayton | 2.7 mi | ★★★★★ | 4 | 0 |
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