Below average — CMS composite of the measures below.
The next survey window likely opens around March 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 Harmony Court Rehab And Nursing during CMS and state inspections, most recent first.
A cognitively impaired resident with dementia and wandering tendencies, care-planned to reside on a secured memory care unit, eloped after staff left the secured unit unattended and an egress door screamer alarm was not sounding loudly. The resident’s spouse twice notified an LPN that the resident reported being at a bus stop, but the initial call was not acted on beyond a failed phone transfer to the RN, and there was a significant delay before staff recognized the resident was missing and began searching. Staff searched the building and surrounding neighborhood, including using private vehicles, but never notified police, and no code E for elopement was called despite a written missing person policy requiring immediate code activation, thorough search, and notification of management, the physician, family, and law enforcement. The resident was ultimately found off facility grounds at a bus stop across a four-lane road and returned, and subsequent review of camera footage and interviews confirmed the unit had been left unattended, alarms were not heard, and staff did not follow the established elopement and missing person protocols.
Improperly labeled and stored insulin was found for five residents whose insulin products were kept in the unit medication cart. An LPN and the DON verified that several insulin vials were either expired or not dated when removed from refrigeration, including products for residents with DM2 who were receiving basal and sliding-scale insulin multiple times per day. The facility policy and pharmacy guidance required dating opened insulin and removing expired medication from active use.
The facility failed to ensure a dignified dining experience by frequently serving meals with plastic cutlery instead of metal utensils due to an inadequate supply of metal utensils and occasional dishwasher issues. During a breakfast meal service, a CNA was observed delivering trays with plastic utensils, and the dietary supervisor confirmed this practice. Several residents with moderate cognitive impairment and multiple comorbidities, including ESRD, COPD, dementia, heart failure, bipolar disorder, and DM2, received plastic cutlery, expressed a preference for metal utensils, and one reported difficulty cutting certain foods with a plastic knife.
A resident with severe cognitive impairment and mental health diagnoses required supervision for multiple ADLs but was observed lying in bed without access to a call light, as the cord was on the floor and too short to reach from the wall to the bed. A CNA confirmed the resident could not reach the call light because of the inadequate cord length, resulting in a failure to reasonably accommodate the resident’s needs for call system access.
A resident with severe cognitive impairment and psychiatric diagnoses was found to be living in a room that was not maintained in a clean and sanitary condition, as spiderwebs were observed above the full width of the sliding glass door. The resident required set-up assistance with oral hygiene and supervision for toileting, bathing, dressing, and personal hygiene, while remaining independent with eating, bed mobility, and transfers. A CNA confirmed the presence of the spiderwebs during an interview, demonstrating a failure to provide a safe, clean, comfortable, and homelike environment.
The facility failed to provide required nail care as part of ADL assistance for two dependent residents with moderate cognitive impairment and multiple chronic conditions, despite care plans directing staff to assist with personal hygiene. Observations showed both residents had long, jagged fingernails with an unknown brown substance underneath, and each resident stated they wanted their nails cut and cleaned. CNAs acknowledged that the residents’ fingernails needed nail care, and this was inconsistent with the facility’s Personal Care Needs policy, which includes nail care as part of personal care and ADL support.
Failure to perform hand hygiene during meal tray delivery. A CNA delivered breakfast trays to three residents and opened one resident’s milk carton without sanitizing hands before or after the interactions. The CNA acknowledged the lapse, and the ICP confirmed staff are to sanitize hands before and after delivering resident meal trays.
The facility failed to implement its abuse policy after two residents in a secured memory care unit were involved in an incident of alleged sexual contact. A cognitively intact resident with a history of sexually inappropriate behavior was observed by therapy staff with his hand on the genital area of another resident with severe dementia, rubbing and squeezing through clothing. A CNA reported the incident to the ADON, and an NP assessed both residents and documented that staff described the behavior as an attempt to ejaculate the cognitively impaired resident, who did not understand what was happening. Despite a facility policy defining sexual abuse as any non-consensual sexual contact, including unwanted touching of the perineal area, the Administrator stated the event was not sexual abuse or reportable because both residents were clothed, and acknowledged that the abuse policy, required reporting to the state, and a thorough investigation were not carried out.
A cognitively intact resident with a history of sexually inappropriate behavior was observed by therapy staff and a CNA with his hand on the genital area of a severely cognitively impaired resident in a common area, rubbing and squeezing through clothing. Nursing and NP documentation described the incident as high-risk sexual behavior, with the impaired resident not understanding what occurred, and guardians were notified. Despite this, the Administrator did not consider the event to be sexual abuse, did not report it to the state agency, and did not ensure a thorough investigation, even though facility policy defined such non-consensual intimate touching as sexual abuse and required prompt reporting and investigation of allegations involving residents who may lack capacity to consent.
The facility failed to investigate an allegation of sexual abuse when a cognitively intact resident with a history of sexually inappropriate behavior was observed by therapy staff with his hand on the genital area of a severely cognitively impaired resident in a secured unit. Staff intervened, separated the residents, and documented that the impaired resident did not appear to understand what had occurred, and that the behavior was characterized as high-risk sexual behavior. Despite this, the Administrator did not treat the event as sexual abuse or initiate a thorough investigation, stating that nothing happened because both residents were clothed, even though the facility’s abuse policy required prompt, thorough investigation and reporting of any alleged non-consensual sexual contact involving a resident lacking capacity to consent.
The facility failed to ensure timely NP documentation, signatures, and dates for required visits for two residents. One resident with multiple comorbidities, including DM, morbid obesity, and a right foot abscess, had NP progress notes for a bedside assessment of high-risk sexual behavior and a visit for DM and obesity entered and signed days to weeks after the actual encounters. Another resident with dementia, HTN, MDD, and DM had NP notes documenting being the recipient of another resident’s inappropriate behavior and a visit for a rash also entered and signed after the dates of service. The NP confirmed during interview that these were late entries and that provider visits were not being documented and signed on the days residents were seen due to her being behind on documentation.
A nurse failed to administer medications as prescribed to a resident with multiple chronic conditions. During a medication pass, the nurse omitted Bumex and Aspirin from the medication cup and provided only one Fluphenazine tablet instead of two, as well as the wrong form of Aspirin. The errors were identified when the resident questioned the missing medications, prompting the nurse to correct the omissions.
A registered nurse failed to administer medications as ordered to a resident with multiple diagnoses, including providing an incorrect dose of Fluphenazine, omitting Bumetanide and Aspirin initially, and substituting an enteric coated Aspirin for the prescribed chewable form. The errors were discovered when the resident questioned the missing medications, leading to an observed medication error rate of 11.11%.
A registered nurse was observed leaving a medication cart unlocked and unattended in the hallway for several minutes while administering medication to a resident. The nurse acknowledged the cart should have been locked, and facility policy requires medications to be stored securely. This lapse had the potential to affect all residents on the hall.
A registered nurse was observed handling medications with bare hands and picking up a dropped pill from the medication cart surface before administering it to a resident with multiple chronic conditions. These actions did not follow CDC standard precautions for infection control during medication administration.
A resident with multiple medical and psychiatric conditions, who was cognitively intact and dependent on staff for ADLs, was subjected to verbal abuse and profane language by an LPN. The incident was witnessed by another nurse and confirmed through facility investigation, violating the facility's zero-tolerance policy for abuse.
A resident with cognitive impairment and a known risk for elopement exited the facility through an alarmed door without staff knowledge. The door alarm was not loud enough to be heard from the nurses' station, and staff on the unit were unaware of the resident's elopement risk. The incident was only discovered after police notified the facility that the resident was outside.
The facility failed to ensure staff donned appropriate PPE for residents on enhanced barrier precautions. A resident with a colostomy and another with a wound required EBP, but staff did not wear gowns during high-contact care activities, as observed with a CNA and an LPN. The facility's policy required gowns and gloves for such interactions.
A facility failed to timely report a misappropriation of a resident's narcotic medication to the Ohio Department of Health. The Director of Nursing received a suspicious photograph of a controlled substance record on a Friday but did not report it until the following Monday, violating the facility's policy requiring 24-hour reporting. The incident involved a registered nurse altering medication records, leading to their termination.
A facility failed to thoroughly investigate the misappropriation of a resident's narcotic medication by an RN and did not protect residents during the investigation. The DON received a suspicious photograph but delayed reporting it, allowing the RN to continue working. The investigation focused only on the RN and did not include other potential staff involvement, contrary to facility policy.
Elopement from Unattended Secured Unit and Failure to Follow Missing Person Policy
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain a safe environment for a cognitively impaired resident assessed as being at risk for elopement and residing on a secured memory care unit. The resident had dementia, hypertension, major depressive disorder, and type 2 diabetes, and the admission baseline care plan specified that the resident should be on a secured unit due to cognitive impairment and wandering tendencies. On the evening in question, the resident’s wife received a call from the resident on his personal cell phone stating he was at a bus stop, and she notified an LPN at the facility that the resident was not in the building. The LPN transferred the call to the RN assigned to the secured unit, but the RN did not answer, and the LPN took no further immediate action to report or search for the missing resident at that time. After the wife’s initial call, there was a delay before staff began actively searching for the resident. The wife called back later asking if the resident had been located, at which point the LPN went to the secured unit and informed the RN that the resident was reportedly not in the facility. The RN and a CNA then realized the resident was not on the unit and began searching within the facility. The CNA subsequently reported to the night shift supervisor that the resident was missing, and staff expanded the search to the exterior of the building and surrounding neighborhood, including use of private vehicles by nursing staff. Despite the resident being missing for an extended period, local police were never notified to assist in the search, contrary to the facility’s Missing Person Policy, which requires immediate paging of a code E for elopement, thorough search, and notification of management, the physician, the resident’s representative, and the police. The investigation determined that the resident likely exited the secured unit via the 400-unit egress door when the unit was unattended by staff. Camera footage showed that the RN and CNA assigned to the secured memory care unit had left the unit and that the unit was unattended at the time the resident eloped, despite a facility policy that secured units are never to be left unattended. The egress door’s secondary screamer alarm was found to be buzzing softly rather than sounding loudly, which would have allowed a person to exit without effectively alerting staff. The resident was ultimately found approximately 0.8 miles from the facility at a bus stop across a four-lane road and returned to the unit. Documentation and staff interviews revealed inconsistencies in the RN’s account of where and how the resident was found, and the facility’s SRI substantiated neglect related to the actions of the RN and CNA assigned to the unit. The facility’s Missing Person Policy, dated July 2020, specified that upon discovery of a missing resident, staff must immediately page a code E, conduct a thorough search, notify the Administrator, DON, physician, and resident’s representative, notify the police, and provide them with identifying and clinical information, as well as continue searching and document the sequence of events. In this incident, staff did not immediately call a code E, did not promptly notify management of the initial report from the resident’s wife, and did not notify local authorities at any point while the resident was missing. The DON later confirmed that staff failed to follow the missing person policy by delaying identification and notification of the resident’s absence and by not contacting the police, contributing to the extended duration of time the resident was missing before being located and returned. The resident was assessed after return and found to be at baseline with no injuries and vital signs within normal limits. The DON and ADON later learned, through review of camera footage and staff interviews, that staff had begun searching for the resident approximately two hours before management was contacted and that no alarms were heard while the resident was missing. The resident himself described his elopement in terms of waiting for the right time, grabbing his jacket, and slipping out, consistent with his cognitive impairment and wandering tendencies. The combination of an unattended secured unit, a malfunctioning or ineffective door alarm, delayed response to the wife’s report, failure to immediately implement the missing person protocol, and failure to notify police constituted the actions and inactions that led to the elopement-related deficiency. The facility identified this as an incidence of past non-compliance that had resulted in Immediate Jeopardy beginning when the wife first reported the resident missing and staff failed to act promptly. The Immediate Jeopardy was tied to the resident’s unsupervised departure from a secured memory care unit, the extended period during which the resident was missing, and the fact that the resident was ultimately found off facility grounds, across a major road, without staff knowledge of his whereabouts. The deficiency was cited under the requirement to ensure the environment is free from accident hazards and that residents receive adequate supervision to prevent accidents, specifically in relation to elopement risk management for residents on secured units. The DON later stated that when she was contacted about the missing resident, staff did not inform her that the resident’s wife had initially reported him missing earlier in the evening. She also acknowledged that calling the police did not occur to her at the time, as she expected the ADON to arrive quickly and manage the situation. The Administrator confirmed that the resident was dressed appropriately for the weather when found. The facility’s investigation concluded that the delayed response in identifying the resident’s absence and notifying appropriate individuals, combined with the ineffective door alarm and the unit being left unattended, resulted in the resident’s elopement and the extended time he remained missing.
Improperly Labeled and Stored Insulin
Penalty
Summary
Drugs and biologicals were not labeled and stored in accordance with accepted professional principles for five residents whose insulin products were kept in the unit-100 medication cart. Resident #26 had diagnoses of diabetes mellitus type two and chronic kidney disease and was ordered Degludec insulin 10 units at bedtime; Resident #55 had diabetes mellitus type two and schizoaffective disorder and was ordered Novolog insulin per sliding scale four times per day; Resident #85 had diabetes mellitus type two and paranoid schizophrenia and was ordered Lispro insulin five units at meals; Resident #86 had diabetes mellitus type two and schizoaffective disorder and was ordered Novolog insulin per sliding scale four times per day and Glargine insulin 25 units every 12 hours; and Resident #99 had diabetes mellitus type two and hypertension and was ordered insulin Aspart seven units with meals and insulin Glargine 32 units at bedtime. MAR review showed these residents received insulin throughout March 2026, including daily or multiple times per day depending on the order. On observation of the medication cart, Resident #26's Degludec insulin was opened on 02/04/26, Resident #55's Novolog insulin was opened on 02/25/26, Resident #85's Lispro insulin was not dated, Resident #86's Novolog and Lantus insulins were both opened on 02/20/26, and Resident #99's Aspart and Glargine insulins were not dated. LPN #225 verified insulin products were to be dated when removed from refrigeration and placed in the cart, with expiration 28 to 30 days after placement, and confirmed the listed insulins were either expired or not properly dated and should have been discarded. The DON also verified insulin products were to be dated when removed from refrigerated storage and placed in the medication cart. The facility's insulin stability chart and medication storage policy stated insulin should be dated and stored according to manufacturer or supplier recommendations, and expired medications should not be administered.
Failure to Provide Dignified Dining Utensils
Penalty
Summary
The facility failed to provide residents with a dignified dining experience by routinely serving meals with plastic cutlery instead of metal utensils. On the nursing 100 Unit dining room, a CNA was observed delivering breakfast trays that included plastic utensils to multiple residents. The CNA confirmed that plastic cutlery was frequently used when the dishwasher was not working or when there were not enough metal utensils available for all residents. The Dietary Supervisor verified that plastic utensils were utilized because the facility did not have an adequate supply of metal utensils. This deficiency affected at least three residents who had moderate cognitive impairment and required either setup assistance or supervision for eating. One resident with ESRD, hypertension, and COPD, another with dementia and major depressive disorder, and a third with hypertensive heart disease with heart failure, bipolar disorder, and type 2 diabetes were all provided plastic cutlery with their breakfast trays. During interviews, these residents stated they preferred metal utensils, and one resident reported difficulty cutting some foods with a plastic knife. The issue had the potential to affect nearly all residents who received meals from the kitchen.
Failure to Keep Call Light Within Reach Due to Inadequate Cord Length
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was kept within reach, as required to reasonably accommodate the resident’s needs and preferences. Medical record review showed the resident was admitted with diagnoses including disorganized schizophrenia, depression, and anxiety, and an MDS assessment documented severe cognitive impairment. The MDS further indicated the resident required set-up assistance with oral hygiene and supervision for toileting, bathing, dressing, and personal hygiene, while being independent with eating, bed mobility, and transfers. During an observation, the resident was seen lying in bed with the call light cord on the floor and out of reach, and the cord was noted to be too short to extend from the wall to the resident’s bed. In an interview, a CNA confirmed that the resident did not have access to the call light because the cord was not long enough to reach the bed. This combination of the resident’s severe cognitive impairment, need for supervision with ADLs, and the physical placement and length of the call light cord resulted in the resident not having access to the call system while in bed, constituting the cited deficiency.
Failure to Maintain Clean and Sanitary Resident Room Environment
Penalty
Summary
The facility failed to ensure a clean and sanitary resident room environment, resulting in spiderwebs being present above the entire width of a resident’s approximately six-foot-wide sliding glass door. The resident involved had an admission date of 09/09/24 and diagnoses including disorganized schizophrenia, depression, and anxiety. A Minimum Data Set (MDS) assessment dated 03/05/26 documented that the resident had severe cognitive impairment, required set-up assistance with oral hygiene, supervision for toileting, bathing, dressing, and personal hygiene, and was independent with eating, bed mobility, and transfers. On 03/30/26 at 11:09 A.M., observation of the resident’s room revealed spiderwebs above the sliding glass door, indicating the room was not maintained in a clean and sanitary condition. At 11:10 A.M., CNA #344 was interviewed and verified the presence of spiderwebs above the sliding glass door. This deficiency was identified during an investigation under Complaint Numbers 2563479 and 1348234 and reflects a failure to honor the resident’s right to a safe, clean, comfortable, and homelike environment, including safe supports for daily living.
Failure to Provide Nail Care as Part of ADL Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide nail care as part of activities of daily living (ADL) assistance for dependent residents, as required by their care plans and facility policy. Resident #21, admitted with diagnoses including end-stage renal disease, hypertension, and chronic obstructive pulmonary disease, had a Minimum Data Set (MDS) showing moderate cognitive impairment and a need for staff assistance with ADLs. The resident’s care plan identified an ADL deficit and directed staff to assist with personal hygiene. During an observation, the resident’s fingernails were noted to be long and jagged with an unknown brown substance underneath. The resident stated he wanted his fingernails cut and cleaned, and a CNA confirmed that the resident’s fingernails needed nail care. Resident #82, admitted with diagnoses including paranoid schizophrenia, bipolar disorder, hypertension, and chronic obstructive pulmonary disease, also had an MDS indicating moderate cognitive impairment and a need for staff assistance with ADLs. The resident’s care plan documented an ADL deficit with interventions for staff to assist with personal hygiene. Observation showed this resident’s fingernails were long and jagged with an unknown brown substance underneath. The resident reported wanting his fingernails cut and cleaned, and a CNA verified that the resident’s fingernails required nail care. Review of the facility’s 2024 Personal Care Needs policy showed that personal care and ADL support, including nail care, were to be provided according to the resident’s plan of care, but this was not carried out for these residents.
Failure to Perform Hand Hygiene During Meal Tray Delivery
Penalty
Summary
The facility failed to ensure staff practiced proper hand hygiene while delivering meal trays to residents. During observation on 03/31/26 from 9:31 A.M. to 9:38 A.M., CNA #267 delivered breakfast meal trays in the 100-nursing unit dining room to Residents #21, #51, and #54 without sanitizing hands before or after passing the trays. CNA #267 also opened Resident #21's milk carton and did not sanitize hands before or after assisting the resident. During interview on 03/31/26 at 9:38 A.M., CNA #267 verified she should have sanitized her hands before and after passing a meal tray to each resident. On 04/03/26 at 11:25 A.M., the Infection Control Preventionist verified staff are to sanitize hands before and after delivering a resident meal tray. Review of the facility's Hand Hygiene policy dated February 2026 stated hand hygiene is the primary means to prevent the spread of infection and that staff should practice hand hygiene before and after assisting a resident with meals or passing trays to another resident.
Failure to Implement Abuse Policy After Allegation of Sexual Contact Between Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse policy when an allegation of sexual abuse occurred between two residents in the secured Memory Care Unit. One resident, who was cognitively intact with diagnoses including major depressive disorder, intellectual disability, morbid obesity, pulmonary embolism, and diabetes mellitus, was ordered to reside in a locked men’s unit for safety of self and others. This resident had a known history of sexually inappropriate behaviors with another resident who had since been discharged. The other resident involved had diagnoses including dementia, insomnia, major depressive disorder, hypertension, and diabetes mellitus, and was care planned for impaired cognition with short- and long-term memory impairment and severely impaired decision-making ability. On the date of the incident, staff including a CNA, an OTA, and a PT observed the cognitively intact resident seated next to the severely cognitively impaired resident in a common television room. The OTA and PT reported seeing the cognitively intact resident’s hand on the other resident’s genital area, squeezing and rubbing through clothing. The CNA reported that the therapists told her the same and that she then notified the ADON. Nursing documentation indicated that the cognitively intact resident was observed with hand contact to the other resident’s genital area while both were seated in the common area, and that staff intervened and redirected the resident away. The NP documented, as a late entry, that she was called about the incident, assessed both residents, and was told by staff that the cognitively intact resident was attempting to ejaculate the severely impaired resident by rubbing his penis up and down through clothing, and that the impaired resident did not appear to understand what was happening. Despite these observations and the facility’s written policy defining sexual abuse as non-consensual sexual contact of any type, including unwanted intimate touching of the perineal area, the Administrator did not treat the event as sexual abuse. The Administrator stated he did not consider the incident to be sexual abuse or reportable because both residents were fully clothed and asserted that nothing happened to the cognitively impaired resident. He acknowledged that the cognitively intact resident had a history of sexually inappropriate behavior and that the other resident was severely cognitively impaired and unable to consent to being touched in that manner. The Administrator further verified that the facility did not implement its abuse policy, did not report the allegation to the state agency, and did not complete a thorough investigation as required by the facility’s abuse, neglect, and misappropriation policy, which mandates prompt and thorough investigation and immediate reporting of any abuse allegations to the Administrator/designee and the Department of Health and social services, and requires that any situation where a resident may not have capacity to consent to sexual activity be treated as alleged sexual abuse. Additional documentation showed that after the incident, the cognitively intact resident was given an order for medroxyprogesterone for high-risk sexual behavior and was later care planned for sexually inappropriate behaviors with other residents, and an IDT note described another observation of this resident placing his hand on another resident’s perineal area. However, the medical records for both involved residents contained no documented evidence that either was evaluated by psychiatric services immediately following the initial incident. Interviews with the NP and staff confirmed that the NP was informed of the sexually inappropriate contact, assessed both residents, and communicated with the MD and DON, but the facility still did not activate its formal abuse investigation and reporting process as outlined in its policy. This sequence of events and omissions led to the cited deficiency for failure to implement the abuse policy in response to an allegation of sexual abuse.
Failure to Report and Investigate Alleged Sexual Abuse Between Residents
Penalty
Summary
The deficiency involves the facility’s failure to recognize and report an allegation of sexual abuse between two residents, and to conduct a thorough investigation, as required by facility policy and state reporting requirements. One resident, who was cognitively intact and had a history of sexually inappropriate behavior, was housed on a secured men’s memory care unit under an order for placement there for safety of self and others related to major depressive disorder. Another resident on the same secured unit had severe dementia, impaired cognition, and required assistance with decision-making. On the date of the incident, staff, including therapy personnel and a CNA, observed the cognitively intact resident with his hand on the genital area of the severely cognitively impaired resident, rubbing and squeezing through clothing while both were seated in a common area. Multiple staff members provided consistent accounts of the event. A CNA reported that two therapists had seen the cognitively intact resident with hand contact to the other resident’s genital area, caressing and rubbing through his pants. The Occupational Therapy Assistant stated she observed the resident’s hand around the other resident’s penis, squeezing and rubbing it, and reported this to the CNA. The Physical Therapist similarly reported seeing the resident’s hand on the other resident’s genital area. Nursing documentation for both residents recorded that the incident involved hand contact to the genital area in the common area, that staff intervened and separated the residents, and that guardians were notified. A Nurse Practitioner documented, as a late entry, that she was called about the incident, assessed both residents, and was told by staff that the cognitively intact resident was attempting to ejaculate the severely demented resident, who did not appear to understand what was happening. Despite these observations and documentation, the Administrator did not report the incident to the state agency via the Self-Report Incident (SRI) system and acknowledged that no thorough investigation was completed. The Administrator stated he did not consider the event to be sexual abuse and believed it was not reportable because both residents were fully clothed and he felt that “nothing happened” to the cognitively impaired resident. This position was taken even though the Administrator verified that one resident was cognitively intact, had a history of sexually inappropriate behavior, and the other resident was severely cognitively impaired and unable to consent to being touched in that manner. The facility’s own abuse policy defined sexual abuse as non-consensual sexual contact of any type, including unwanted intimate touching of the perineal area, and required that any allegation involving a resident who may not have capacity to consent be treated as alleged sexual abuse and promptly reported and investigated. The Administrator confirmed that, under this policy, the incident should have been reported and thoroughly investigated, but it was not. Additional documentation showed that after the incident, the cognitively intact resident was given an order for medroxyprogesterone for high-risk sexual behavior and a behavioral care plan for sexually inappropriate behaviors with other residents was created. An IDT note later described another observation of the same resident placing his hand on another resident’s perineal area, after which he was moved to a private room and seen by a psychiatric provider. However, for the original incident involving the severely cognitively impaired resident, there was no documented evidence that either resident was evaluated by psychiatric services at that time. The failure identified by surveyors centered on the facility’s noncompliance with its abuse policy and regulatory requirements: specifically, not reporting the allegation of sexual abuse to the proper authorities and not conducting a prompt and thorough investigation of the incident between the two residents. The facility’s written policy on Abuse, Neglect, Misappropriation of Resident Property, and injury of unknown origin, dated August 2024, assigned the Administrator responsibility for implementing the abuse/neglect program and required that any reports of abuse be promptly and thoroughly investigated and immediately reported to the Administrator/designee and to the Department of Health and social services. The policy explicitly stated that sexual abuse includes unwanted intimate touching of the perineal area and that if there is an allegation that a resident did not consent or may not have capacity to consent to sexual activity, the facility must respond as an alleged violation of sexual abuse and provide immediate safety measures. In this case, despite staff observations and documentation consistent with non-consensual sexual contact involving a resident lacking capacity to consent, the Administrator did not follow the policy’s reporting and investigation requirements, resulting in the cited deficiency.
Failure to Investigate Alleged Sexual Abuse Between Cognitively Intact and Severely Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to investigate an allegation of sexual abuse between two residents in the secured Memory Care Unit (MCU). Resident #01, who was cognitively intact with diagnoses including major depressive disorder, morbid obesity, pulmonary embolism, intellectual disability, essential primary hypotension, and diabetes mellitus, was ordered to reside in the secured unit for safety of self and others. Resident #12, who had diagnoses including dementia, insomnia, essential primary hypertension, major depressive disorder, and diabetes mellitus, was care planned as having impaired cognition with short- and long-term memory impairment and severely impaired cognition on the MDS, requiring assistance with decision-making. The facility’s abuse policy defined sexual abuse as non-consensual sexual contact of any type, including unwanted intimate touching of the perineal area, and required that any allegation involving a resident who may not have capacity to consent be treated as alleged sexual abuse and promptly and thoroughly investigated. On 01/28/26, CNA #222 was alerted by OTA #177 and PT #189, who observed Resident #01 seated next to Resident #12 on a couch in the men’s secured unit. OTA #177 reported seeing Resident #01’s hand around Resident #12’s penis, squeezing and rubbing it through clothing, and PT #189 similarly observed Resident #01’s hand on Resident #12’s genital area. CNA #222 reported the incident to ADON #258. Nurse progress notes for both residents documented that Resident #01 had hand contact with Resident #12’s genital area while both were seated in the common area, that staff intervened and redirected Resident #01 away from Resident #12, and that guardians and other parties were notified. NP #501 documented, as a late entry, that staff reported Resident #01 was witnessed attempting to ejaculate Resident #12, that Resident #12 did not appear to understand what had happened, and that Resident #12 was the receiver of another resident’s high-risk sexual behavior. Despite these observations and documentation, the facility did not conduct a thorough investigation of the alleged sexual abuse as required by its abuse policy. The Administrator stated he did not consider the incident to be sexual abuse and did not report it externally because both residents were fully clothed and he believed “nothing happened” to Resident #12, even while acknowledging that Resident #01 was cognitively intact, had a history of sexually inappropriate behavior, and that Resident #12 was severely cognitively impaired and unable to consent to being touched in that manner. The medical records for both residents lacked documented evidence that either resident was evaluated by psychiatric services after the 01/28/26 incident, despite NP documentation indicating high-risk sexual behavior and severe cognitive impairment of the involved residents. The Administrator later verified that the facility did not complete a thorough investigation related to the incident, in contradiction to the facility’s written abuse policy requiring prompt and thorough investigation and immediate reporting of such allegations.
Untimely NP Documentation and Signatures for Resident Visits
Penalty
Summary
The deficiency involves the facility’s failure to ensure that physician and NP visits were signed and dated in a timely manner at each required visit for two residents. For one resident with diagnoses including right foot abscess, major depressive disorder, morbid obesity, hypertensive retinopathy, pulmonary embolism, insomnia, intellectual disability, essential primary hypotension, and diabetes mellitus, the medical record showed late-entry NP progress notes. One late entry documented a bedside assessment for high-risk sexual behavior and was recorded for a date in January but not authored and signed until early February. Another late entry documented a provider visit related to diabetes and morbid obesity, also recorded for an earlier date but not authored and signed until several days later. For a second resident with insomnia, dementia, essential primary hypertension, major depressive disorder, and diabetes mellitus, similar late-entry NP documentation was identified. One late entry described the resident as the recipient of another resident’s inappropriate behavior and was recorded for a January date but not authored and signed until early February. Another late entry documented a visit for a rash, with the note recorded for one date and authored and signed two days later. During an interview, the NP confirmed that she created and signed the late-entry progress notes for both residents on a later date than when the residents were seen and acknowledged that provider visits were not being documented and signed on the days the residents were actually seen, stating she was behind on documentation due to workload.
Failure to Administer Medications as Prescribed
Penalty
Summary
A deficiency occurred when a registered nurse failed to administer medications as prescribed to a resident with multiple diagnoses, including schizoaffective disorder, COPD, major depressive disorder, and syndrome of inappropriate secretion of anti-diuretic hormone. During a medication pass, the nurse prepared and presented a medication cup to the resident, who noticed that her Bumex (diuretic) and Aspirin (salicylate) were missing. The nurse then returned to the medication cart to retrieve and administer the missing medications after being prompted by the resident. Further review of the resident's physician orders revealed that Fluphenazine was to be given as two 10 mg tablets twice daily, but only one tablet was prepared and administered. Additionally, the nurse provided an 81 mg enteric-coated Aspirin instead of the prescribed chewable tablet. The nurse acknowledged these errors during an interview, confirming that the medications were not prepared or administered as ordered until the resident pointed out the omissions.
Medication Administration Errors Result in Elevated Error Rate
Penalty
Summary
The facility failed to ensure medications were administered as ordered, resulting in three medication errors out of 27 opportunities observed, which equated to an 11.11% medication error rate. During a medication pass, a registered nurse prepared and administered medications to a resident with multiple diagnoses, including schizoaffective disorder, COPD, major depressive disorder, and syndrome of inappropriate secretion of anti-diuretic hormone. The nurse prepared only one 10 mg tablet of Fluphenazine instead of the ordered two tablets, omitted Bumetanide (Bumex) and Aspirin from the initial medication cup, and later provided an enteric coated Aspirin instead of the prescribed chewable tablet. The errors were identified when the resident questioned the absence of Bumex and Aspirin in the medication cup, prompting the nurse to review the orders and subsequently provide the missing medications. The nurse acknowledged the errors during an interview, confirming the incorrect dosage and formulation of medications administered. These actions resulted in a medication error rate above the acceptable threshold, affecting one resident reviewed for medication administration.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A registered nurse was observed preparing medication for a resident, removing the medication cup from the cart, and then walking approximately five feet down the hall to enter the resident's room, leaving the medication cart unlocked and unattended in the hallway for about four minutes. During an interview, the nurse acknowledged that the cart should not have been left unlocked and unattended. Review of the facility's medication storage policy confirmed that medications are required to be stored safely and securely. This failure to secure the medication cart had the potential to affect all 25 residents on the hall, with a facility census of 107.
Failure to Follow Infection Control Practices During Medication Administration
Penalty
Summary
During a medication administration observation, a registered nurse was seen removing medications from a medication card by punching them directly into his ungloved hand before placing them into a medication cup. This process was repeated for a second medication. The nurse acknowledged during an interview that medications should not be handled with bare hands and should be transferred directly into the medication cup. Further observation revealed that when the nurse attempted to punch a medication into the cup, the pill missed and landed on the medication cart. The nurse then picked up the medication from the cart surface with his ungloved fingers and placed it into the medication cup. The resident involved had multiple diagnoses, including COPD, hemiplegia, bipolar disorder, and depression, and required supervision for several activities of daily living. These actions were not in accordance with CDC standard precautions for infection control and medication safety.
Verbal Abuse of Resident by LPN
Penalty
Summary
A deficiency occurred when a resident, who had diagnoses including hemiplegia, hemiparesis following cerebral infarction, anxiety disorder, bipolar disorder, post-traumatic stress disorder, and aphasia, was subjected to verbal abuse by a staff member. The resident was cognitively intact and required staff assistance with activities of daily living. On the date of the incident, a Licensed Practical Nurse (LPN) used profane language and spoke in a verbally abusive manner toward the resident, an event witnessed by both the resident and another nurse. The facility's self-reported incident documentation and interviews confirmed that the verbal abuse took place, which was in direct violation of the facility's zero-tolerance policy for abuse, including verbal abuse. The incident was substantiated through the facility's investigation, which included review of the medical record, staff interviews, and policy review.
Resident Elopement Due to Inaudible Door Alarm and Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with a history of Alzheimer's disease, psychotic disorder, and Parkinson's disease, who was assessed as being at risk for elopement due to wandering behaviors and cognitive impairment, exited the facility through an alarmed door without staff knowledge. The resident was independently mobile with a walker and required supervision for activities of daily living. The care plan identified the risk for elopement and included interventions such as redirection and structured activities, but these were not sufficient to prevent the incident. On the day of the event, two aides were present on the unit and were unaware of the resident's elopement risk. The door alarm, which was intended to alert staff to unauthorized exits, was not loud enough to be heard from the nurses' station where the aides were located. The aides only became aware of the resident's exit after being notified by staff from another unit, who had been contacted by the police upon finding the resident outside. Facility staff interviews and observations confirmed that the alarm was not audible from the nurses' station and that maintenance had not been asked to adjust the alarm volume following the incident.
Failure to Don PPE for Residents on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff donned appropriate personal protective equipment (PPE) prior to providing care for residents on enhanced barrier precautions (EBP). This deficiency was observed in two residents. Resident #13, who was admitted with diagnoses including hypotension, gastrotomy, colostomy, obesity, and dysphagia, required EBP due to an indwelling medical device (colostomy). The care plan for Resident #13 specified that staff should don gowns and gloves during high-contact resident care activities. However, during an observation of incontinence care, a Certified Nursing Assistant (CNA) did not don a gown prior to providing care, which was confirmed in an interview with the CNA. Similarly, Resident #11, admitted with diagnoses including bipolar disorder, schizophrenia, and psychotic disorder, required EBP due to a left ankle wound. The care plan for Resident #11 also required staff to don gowns and gloves during high-contact care activities. During an observation of wound care, a Licensed Practical Nurse (LPN) did not don a gown prior to providing care, which was confirmed in an interview with the LPN. The facility's policy on Enhanced Barrier Precautions, dated March 2024, indicated that EBP measures included donning gowns and gloves during high-contact resident care activities for residents with indwelling medical devices and wounds, even if the resident was not known to be infected or colonized with an infection.
Delayed Reporting of Medication Misappropriation
Penalty
Summary
The facility failed to report an allegation of misappropriation of a resident's narcotic medication in a timely manner to the Ohio Department of Health (ODH). The incident involved a resident whose controlled substance record was altered by a registered nurse (RN), who signed out doses of medication but included another resident's name on the record. The Director of Nursing (DON) received a photograph of this suspicious record from a licensed practical nurse (LPN) on a Friday evening, but did not act on the information until the following Monday. This delay in reporting the incident to the facility administrator and subsequently to the ODH was a violation of the facility's policy, which requires such allegations to be reported within 24 hours. The facility's policy on abuse, neglect, and misappropriation of resident property clearly states that any allegations of misappropriation, including missing prescription medications or diversion of a resident's medication, must be reported to the state agency within 24 hours. Despite this, the DON did not notify her supervisor or the administrator until three days after receiving the initial report of the suspicious activity. The facility substantiated the misappropriation and terminated the RN involved, but the delay in reporting the incident to the ODH constituted noncompliance with the established policy.
Failure to Investigate Misappropriation of Medications
Penalty
Summary
The facility failed to conduct a thorough investigation of misappropriation of resident medications and did not protect residents during the investigation. This deficiency affected one resident and had the potential to affect all residents in the facility. The incident involved the misappropriation of narcotic medication, oxycodone, belonging to a resident by a registered nurse (RN). The Director of Nursing (DON) received a suspicious photograph from a Licensed Practical Nurse (LPN) showing the RN's initials on a controlled substance record with another resident's name written in the margin. Despite the suspicious nature of the photograph, the DON did not report the information to her supervisor until three days later, allowing the RN to continue working during that time. The facility's investigation was not thorough, as it focused solely on the RN and did not include other nurses who might have been involved. The facility's policy required immediate suspension of the alleged perpetrator pending investigation results, but the RN was not suspended until the investigation began. The Administrator confirmed that the facility did not report the allegation to the Ohio Department of Health (ODH) until the investigation was initiated. The facility's policy also required a comprehensive investigation involving interviews with all relevant individuals, which was not conducted.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 894 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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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A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
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) |
|---|---|---|---|---|
| Woods Edge Rehab And Nursing | 0.7 mi | ★★★★★ | 21 | 1 |
| Daniel Drake Center For Post-acute Care Llc | 1.8 mi | — | 0 | 0 |
| Norwood Towers Post-acute | 1.9 mi | ★★★★★ | 30 | 0 |
| Wellspring Health Center | 2.1 mi | ★★★★★ | 13 | 0 |
| Pleasant Ridge Healthcare Center | 2.2 mi | ★★★★★ | 0 | 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.