Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Indianspring Of Oakley during CMS and state inspections, most recent first.
A resident with significant mobility impairments and a history of falls was left dependent on a single CNA for incontinence care, despite care plans and therapy evaluations indicating the need for two-person assistance. During care, the CNA rolled the resident away from herself, contrary to best practices, and the resident fell from the raised bed after a coughing episode, resulting in a hip fracture that required surgical repair.
A resident with severe cognitive impairment and a stage II sacral pressure ulcer was discharged without accurate or complete information being provided to family and home health staff. The discharge summary omitted the presence of a wound and the necessary wound care orders, and the home health agency was not promptly notified of the discharge, resulting in delayed care and an increase in wound size.
A resident with severe cognitive impairment and high fall risk, dependent on staff for all care, was injured after falling from bed during personal care when only one CNA was present instead of the required two-person assist. The CNA, unaware of the autofirm mattress function, attempted to pull a draw sheet, causing the resident to roll over the mattress guard and fall. The facility's fall investigation was incomplete, lacking a thorough root cause analysis.
A facility failed to ensure proper medication administration when an LPN did not prime an insulin pen before giving insulin to a resident with diabetes. The resident, who had intact cognition and required assistance with daily activities, was ordered Humalog insulin per a sliding scale. The LPN confirmed not following the manufacturer's instructions to prime the pen, leading to a significant medication error.
A facility failed to ensure safe and secure medication storage, affecting a resident who had two medication cups at her bedside, one with atorvastatin and another with seven various medications. The resident did not recall when the medications were from and chose not to take them due to feeling unwell. The ADON confirmed the presence of these medications, and a policy review showed that staff should remain with residents until medications are swallowed.
The facility failed to adequately assess and monitor a resident's skin, leading to the development of a stage three pressure ulcer on the right ischium. The resident, admitted without pressure ulcers and at moderate risk, did not receive proper skin assessments or preventive care, resulting in actual harm.
The facility failed to implement nutritional interventions for a resident with significant weight loss in a timely manner. Despite being identified as at risk for malnutrition, the resident experienced a significant weight loss of 12.1% over thirty days, and the dietitian's recommendation for fortified pudding was not implemented. Weekly weights were also delayed, leading to the deficiency.
Failure to Provide Adequate Supervision and Safe Positioning During Incontinence Care Resulting in Resident Injury
Penalty
Summary
Facility staff failed to safely and properly position a resident in bed during incontinence care, resulting in an accident that caused actual harm. The resident involved had significant medical conditions, including end stage renal disease, a left below the knee amputation, diabetes mellitus, and intellectual disabilities. Occupational therapy evaluation and the resident's care plan indicated that the resident required assistance from two staff members for bed mobility due to impaired mobility and balance. However, the care plan was revised to indicate total dependence on one staff member, despite the resident's decline in condition prior to the incident. On the day of the incident, a CNA provided incontinence care to the resident alone. The CNA rolled the resident onto his left side, away from where she was standing, while the bed was raised to her waist height. During care, the resident began coughing uncontrollably, which caused his upper body to shift and led to him falling off the bed and onto a floor mat. The CNA was unable to prevent the fall. The resident subsequently complained of pain in his right hip, and an x-ray revealed a nondisplaced right intertrochanteric hip fracture, which required surgical repair. Staff interviews confirmed that residents should not be rolled away from the caregiver, and that this resident should have been assisted by two staff members due to his condition. The facility's own policy and clinical resources emphasize the importance of proper positioning and adequate assistance to prevent accidents. The failure to follow these protocols and the care plan resulted in the resident sustaining a serious injury.
Failure to Communicate Accurate Discharge Information and Orders
Penalty
Summary
The facility failed to ensure that appropriate and accurate information was communicated to a resident's family and home health provider upon discharge. A resident with severe cognitive impairment, multiple medical diagnoses, and a newly developed stage II sacral pressure ulcer was discharged back to her group home. The discharge summary provided to the family and home health case manager incorrectly stated that the resident had no skin impairment and did not include the current physician's order for wound care. Additionally, the discharge medication list omitted the wound care order that was in place at the time of discharge. The home health agency did not receive confirmation of the resident's discharge until several days after the actual discharge date, and the necessary physician orders were not printed by the agency until even later. As a result, the initial home health nursing visit occurred after a delay, during which time the resident's wound had increased in size. Interviews with facility and home health staff confirmed the lack of timely and accurate communication regarding the resident's discharge status and care needs, in contradiction to the facility's own discharge planning policy.
Failure to Provide Adequate Supervision and Safe Assistance During Personal Care Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, hemiplegia, and a high risk for falls was not safely assisted during personal care, resulting in a fall with significant injuries. The resident required extensive assistance from two staff members for bed mobility, toileting, and transfers, as documented in the care plan. However, during incontinence care, only one CNA was present and attempted to pull a draw sheet from under the resident, which caused the resident to roll over the mattress guard and fall to the floor. The resident sustained traumatic injuries to the face and head and was subsequently transported to the hospital. The investigation revealed that the CNA was unaware of the autofirm function on the alternating pressure mattress, which could have provided a firmer surface for care and potentially prevented the fall. The CNA reported not being trained on this feature prior to the incident. The facility's documentation showed that the care plan required two-person assistance, but only one staff member was present at the time of the fall. Additionally, the mattress in use had side bolsters, which may have contributed to the difficulty in safely repositioning the resident. A review of the facility's fall investigation process found it to be incomplete, as only a single statement from the involved CNA was provided and there was no evidence of a thorough root cause analysis. The IDT follow-up note did not identify the root cause of the fall, and the facility's fall and accident management policy was not fully implemented. Observations and interviews confirmed that the resident was dependent on staff for all care and unable to protect herself from falls, highlighting the lack of adequate supervision and hazard mitigation during personal care.
Failure to Prime Insulin Pen Before Administration
Penalty
Summary
The facility failed to ensure that staff properly primed an insulin pen before administering insulin to a resident. This deficiency was identified during a review of medical records, observations, staff interviews, and manufacturer instructions. Specifically, a Licensed Practical Nurse (LPN) administered two units of Humalog Kwik Pen insulin to a resident without priming the pen as required. The manufacturer's instructions clearly state that the pen should be primed by selecting two units, holding the pen with the needle pointing up, and pushing the dose knob until it stops and zero is seen in the dose window. The LPN confirmed during an interview that she did not prime the insulin pen prior to administration. The resident involved in this incident had a medical history that included type two diabetes mellitus, chronic pulmonary edema, and congestive heart failure. The resident was assessed to have intact cognition and required assistance with various activities of daily living. The physician's order for the resident included the administration of Humalog insulin using a sliding scale. The failure to prime the insulin pen as per the manufacturer's instructions represents a significant medication error, as it could potentially affect the accuracy of the insulin dose administered.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure medications were stored in a safe and secure manner, affecting one of four residents observed for medications. During an observation and interview, it was verified that a resident had two medication cups at her bedside, one containing atorvastatin and the other containing seven various medications. The resident stated she did not recall when the medications were from and chose not to take them because she had not been feeling well. The Assistant Director of Nursing confirmed the presence of these medications at the resident's bedside. A review of the facility's policy on oral medication administration revealed that the nurse or medication aide is required to remain with the resident until the medication is swallowed. This deficiency was identified during an investigation under a specific complaint number.
Failure to Prevent and Monitor Pressure Ulcers
Penalty
Summary
The facility failed to adequately assess and monitor a resident's skin, resulting in the development of a stage three pressure ulcer on the right ischium of Resident #20. The resident, who was admitted without pressure ulcers and had diagnoses including Alzheimer's disease, anemia, atherosclerotic heart disease, and hypertension, was found to have a stage three pressure ulcer that was not identified until it had reached an advanced stage. Weekly skin round assessments did not include documentation regarding the resident's right ischium, and the care plan, which included interventions for skin impairment, was not effectively implemented. The pressure ulcer risk assessment indicated the resident was at moderate risk, but the necessary preventive measures were not adequately followed. The wound was first observed by staff on 03/19/24 and assessed by the Wound Nurse Practitioner on 03/20/24, who confirmed it as a stage three pressure ulcer. The facility's policy on skin monitoring was not adhered to, as the skin assessments were incomplete and the nursing assistant failed to report new or abnormal skin conditions to the nurse. The facility's failure to conduct comprehensive skin assessments and monitor the resident's skin condition led to the development of the pressure ulcer, which was confirmed by the Assistant Director of Nursing. The facility's noncompliance with the National Pressure Ulcer Advisory Panel guidelines and their own policies resulted in actual harm to the resident.
Failure to Implement Nutritional Interventions for Resident with Significant Weight Loss
Penalty
Summary
The facility failed to implement nutritional interventions for a resident with significant weight loss in a timely manner. Resident #20, who had diagnoses including Alzheimer's disease, anemia, atherosclerotic heart disease, and hypertension, was cognitively impaired and dependent on staff for eating and other activities of daily living. Despite being identified as at risk for malnutrition, the facility did not promptly implement the recommended nutritional interventions. The resident experienced a significant weight loss of 12.1% over thirty days, and the dietitian's recommendation for fortified pudding at lunch and dinner was not implemented as a physician's order. Additionally, weekly weights were not ordered until 03/18/24, despite the resident's ongoing weight loss and nutritional needs. Observations of meal service revealed that Resident #20 was dependent on staff for feeding, and interviews with the registered dietitian confirmed the delays in implementing the necessary interventions. The facility's policy on weight monitoring required nursing staff and the dietitian to evaluate and implement nutritional interventions and monitor residents' weight status. However, the policy was not followed in this case, leading to the deficiency. This deficiency was investigated under Complaint Number OH00152496.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Cincinnati
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St. Theresa Care Center | 0.5 mi | ★★★★★ | 3 | 0 |
| Ayden Healthcare Of Madeira | 1.5 mi | ★★★★★ | 32 | 0 |
| Deupree Cottages | 2 mi | ★★★★★ | 0 | 0 |
| Arc At Cincinnati | 2 mi | ★★★★★ | 38 | 0 |
| Madeira Healthcare Center | 2.4 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.