Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Kenwood Terrace Healthcare Center during CMS and state inspections, most recent first.
A deficiency was identified when hot water temperatures in multiple rooms were found to be below the required range, affecting several residents and potentially impacting many more. Facility leadership confirmed ongoing issues with mixing valves and acknowledged missing water temperature monitoring logs for two months.
A resident dependent on a mechanical lift for transfers sustained a forehead injury when the lift malfunctioned due to a broken mechanical strut, causing it to tilt and the sling bar to strike the resident. Facility records and interviews confirmed that required routine inspections and maintenance of the lift had not been performed or documented, leading to the equipment failure and incident.
The facility failed to store food properly and maintain kitchen equipment in a sanitary manner, affecting all 82 residents. Observations revealed undated food items in the refrigerator, freezer, and pantry, dented cans in dry storage, and a dirty microwave. The Executive Chef confirmed these issues, which violated the facility's food storage policy.
The facility failed to complete discharge MDS assessments in a timely manner for two residents, affecting compliance with regulatory requirements. One resident with multiple diagnoses, including COPD and acute kidney failure, was discharged without a completed assessment. Another resident with conditions such as spinal fusion and cognitive communication deficit was also discharged without a timely assessment. An MDS nurse confirmed the delay in completing these assessments.
The facility failed to conduct required care conferences for two residents, impacting their involvement in care planning. One resident with multiple health issues did not have documented conferences in two quarters of 2024, and was unaware of any care discussions. Another resident with chronic conditions also lacked documented conferences in two quarters, despite policy requirements for resident involvement.
Two residents were administered antipsychotic medications without appropriate indications. One resident with intact cognition was given Seroquel despite no documented need, while another with severe cognitive impairment was prescribed olanzapine for insomnia without a suitable diagnosis. These actions were confirmed by facility staff.
A resident with multiple health conditions experienced a critically low blood sugar level, but the facility failed to promptly notify the physician of this critical lab result. The lab work was completed and results were available, but the physician was not informed until the following day, contrary to the facility's policy on critical value management.
A resident with a history of cognitive impairments was admitted to an LTC facility with both upper and lower dentures, but later reported missing the lower set. Despite the resident's difficulty chewing and the absence of a documented item inventory list, the facility failed to arrange for dental services to address the issue. Interviews confirmed the lack of documentation or action taken to resolve the missing dentures.
A resident with multiple health conditions, including vascular dementia, expressed a preference for showers twice weekly, which was not consistently honored by the facility. Despite being cognitively intact and having communicated her preference, the resident mostly received bed baths over a three-month period. Interviews confirmed the resident's dissatisfaction and a CNA acknowledged the inconsistency in providing showers.
A facility failed to include a spinal cord stimulator in a resident's care plan, despite the resident's history of back surgeries and chronic pain. The resident managed the device independently, and staff interviews revealed a lack of awareness about the device, leading to incomplete care planning.
A facility failed to store medications properly in the medication cart, affecting residents prescribed iron. An observation revealed an unlabeled cup with green tablets in the cart. An LPN confirmed these were iron pills not stored correctly. The facility's policy required proper storage of medications.
A Dietary Manager was observed touching hamburger buns with bare hands during lunch preparation, violating the facility's policy on sanitary food handling. The manager confirmed the action, which was against the requirement to use serving utensils to prevent cross-contamination. This was noted during a complaint investigation.
The facility failed to follow infection prevention procedures during medication administration, affecting two residents. An RN used bare hands to handle medications for a resident with major depressive disorder and another with chronic heart failure, contrary to the facility's policy against touching medications and discarding dropped ones.
The facility failed to notify three residents of their Medicaid account balances, which exceeded the SSI resource limit, potentially affecting their Medicaid eligibility. Despite having intact cognition, the residents did not receive required notifications when their balances were within $200 of the limit. The Business Office Manager confirmed the lack of notifications, which is against the facility's policy.
The facility failed to investigate grievances and communicate findings to residents or their representatives, affecting two residents. One resident's family member filed a grievance regarding care concerns, but the facility did not provide investigation results. Another resident's family member also filed a grievance and requested a report, but was told it only goes to the State, with no results provided. The Executive Director confirmed the facility's failure to investigate and communicate grievance resolutions.
The facility failed to securely store medications for three residents. A resident had Fluticasone Propionate unsecured in their room, another had Gabapentin and Hydroxyzine without physician orders, and a third had an unsecured bottle of Betadine. Staff confirmed these medications should not have been left in the residents' rooms.
Failure to Maintain Adequate Hot Water Temperatures
Penalty
Summary
The facility failed to maintain a comfortable hot water supply for residents, staff, and the public, as evidenced by observations, interviews, and review of facility water temperatures. On the date of observation, hot water temperatures in several resident rooms and empty rooms ranged from 95 to 102 degrees Fahrenheit, which is below the expected regulatory range of 105-120 degrees Fahrenheit. The Administrator verified these temperatures at the time of observation. Four residents were specifically reviewed for hot water temperatures, and the issue had the potential to affect 59 residents residing on multiple hallways within the facility. Interviews with the Administrator and DON confirmed ongoing problems with the facility's mixing valves, and a company had recently serviced the system. Both acknowledged that there had been resident complaints about water temperature in the past, though not recently. Additionally, the facility was unable to provide water temperature monitoring logs for the months of May and June, as the maintenance department had not completed this required monitoring. The deficiency was investigated under a specific complaint number.
Failure to Maintain and Inspect Mechanical Lifts Resulting in Resident Injury
Penalty
Summary
The facility failed to properly maintain and inspect mechanical lifts used for resident transfers, resulting in an incident involving a resident with multiple medical conditions, including cardiomegaly, congestive heart failure, morbid obesity, and cervical stenosis. The resident, who was dependent on staff for mobility and required a two-person mechanical lift for all transfers, was being moved when the lift tilted to the right and the sling bar struck the resident on the forehead, causing moderate swelling. The incident occurred while two staff members were assisting the resident, and it was later determined that a mechanical strut on the lift had broken, causing the floor legs to fold back and the lift to tilt. Review of facility records revealed that no routine inspections or maintenance had been completed or documented for the mechanical lifts in use, despite manufacturer guidelines requiring inspection of all mechanical parts at least every six months. Interviews with facility leadership confirmed the absence of inspection records. The lack of proper maintenance and inspection of the mechanical lift directly contributed to the equipment failure and subsequent resident injury.
Deficiency in Food Storage and Kitchen Sanitation
Penalty
Summary
The facility failed to ensure food was stored and kitchen equipment was maintained in a sanitary manner, potentially affecting all 82 residents. During an observation of the facility kitchen, it was found that the walk-in refrigerator contained marinara sauce and two whipped toppings without expiration dates, and the freezer had opened cauliflower also lacking an expiration date. In the pantry, open packages of raisin bran, toasted oats, marshmallows, and cornbread were found without expiration dates. Additionally, a container of oregano on the spice shelf had an expiration date of 09/28/23. In the dry storage area, severely dented cans of mandarin oranges and pumpkin were placed on the shelf for facility use. A large amount of debris with a strong odor was observed in the microwave. An interview with the Executive Chef confirmed the improper dating of food items, the presence of dented cans in dry storage, and the unclean appearance of the microwave. The Executive Chef stated that dented cans were supposed to be placed on the bottom shelf to be sent back and that the microwave was supposed to be cleaned once per shift. The facility's policy on food storage, dated 08/20/18, requires all food to be stored in sealed containers and labeled with dates.
Failure to Complete Timely Discharge MDS Assessments
Penalty
Summary
The facility failed to complete discharge Minimum Data Set (MDS) assessments in a timely manner for two residents, affecting their compliance with regulatory requirements. Resident #63, who had multiple diagnoses including chronic obstructive pulmonary disease and acute kidney failure, was discharged to home on 10/09/24 without a completed discharge MDS assessment. Similarly, Resident #82, with conditions such as spinal fusion and cognitive communication deficit, was discharged to home on 10/23/24, also without a completed discharge MDS assessment. An interview with MDS Nurse #495 confirmed that the discharge MDS assessments for both residents were not completed on time, indicating a lapse in the facility's assessment processes.
Failure to Conduct Required Care Conferences
Penalty
Summary
The facility failed to ensure that care conferences were held as required for two residents, affecting their ability to participate in their care planning. Resident #12, who was admitted with multiple diagnoses including end stage renal disease, diabetes, and congestive heart failure, did not have documented care conferences in the second and fourth quarters of 2024. Despite being offered a care conference in the third quarter, there was no evidence of engagement in the other quarters, and the resident was unaware of any discussions regarding her care. Similarly, Resident #38, with diagnoses such as chronic obstructive pulmonary disease and atrial fibrillation, did not have documented care conferences in the first and second quarters of 2024. Although care conferences were held in the third and fourth quarters, there was no documentation of engagement in the earlier quarters. The facility's policy requires that residents and their representatives be informed and involved in care planning, but this was not consistently followed, as verified by the Regional Director of Clinical Operations.
Inappropriate Use of Antipsychotic Medications
Penalty
Summary
The facility failed to ensure that antipsychotic medications were administered to residents for appropriate indications. Resident #241 was admitted with diagnoses including end-stage renal disease, gout, and anemia, but there were no documented indications for the use of antipsychotic medication in the medical record. Despite having intact cognition as per the Minimum Data Set (MDS) assessment, Resident #241 was prescribed 25 mg of Seroquel daily without adequate justification. This was confirmed by the Divisional Director of Clinical Operations during an interview. Similarly, Resident #84, who was admitted with Alzheimer's dementia, cerebrovascular accident with right-side hemiplegia/hemiparesis, and diabetes mellitus type II, was prescribed olanzapine 5 mg at bedtime for insomnia. The MDS admission assessment indicated severe cognitive impairment and frequent incontinence, yet there was no appropriate diagnosis for the use of olanzapine. The Director of Nursing verified that Resident #84 did not have a suitable indication for the antipsychotic medication, highlighting a failure in ensuring medications were used appropriately.
Failure to Promptly Notify Physician of Critical Lab Value
Penalty
Summary
The facility failed to promptly notify a physician of a critical laboratory value for a resident, which constituted a deficiency in care. The resident, who had been admitted with diagnoses including diabetes mellitus type II with diabetic polyneuropathy, chronic obstructive pulmonary disease with lower respiratory infection, and generalized muscle weakness, experienced a change in condition on 07/15/24, feeling lightheaded and dizzy. Laboratory tests were ordered, and results were available on 07/16/24, revealing a critically low blood sugar level. However, the physician was not notified of these critical results until 07/17/24, more than 18 hours after the results were reported. The facility's policy on Critical Laboratory Value Management requires that nurses promptly notify the ordering physician of critical values and document the communication. In this case, there was no documentation of such notification until the following day, as confirmed by the Director of Nursing. This delay in communication could have impacted the resident's care and treatment, as the critical laboratory value was not addressed in a timely manner.
Failure to Provide Prompt Dental Care for Missing Dentures
Penalty
Summary
The facility failed to provide prompt and appropriate dental services for a resident who was missing their lower dentures. The resident, who had a history of schizoaffective bipolar disorder, depression, and dementia, among other conditions, was admitted to the facility with both upper and lower dentures. However, there was no item inventory list upon admission to confirm the presence of the dentures. The resident reported occasional difficulty chewing due to the absence of the bottom dentures, as noted in dietary progress notes. Despite this, the facility did not arrange for dental services to address the missing dentures. Interviews and observations revealed that the resident was only wearing top dentures and could not recall when the bottom dentures went missing. The facility's Regional Director of Clinical Services confirmed that there was no documentation regarding the missing dentures or any arrangements for dental services after the issue was reported. This deficiency affected one of the six residents reviewed for personal property, highlighting a lapse in the facility's responsibility to ensure residents receive necessary dental care.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to honor and promote a resident's choice for bathing, affecting one resident reviewed for activities of daily living. The resident, who was admitted with multiple diagnoses including hemiplegia, chronic kidney disease, and vascular dementia, was found to be cognitively intact and had expressed that the choice of bathing options was very important. Despite this, the resident received only four showers over a three-month period, with the majority of bathing instances being bed baths, contrary to her preference for showers twice weekly. Interviews with the resident confirmed her dissatisfaction with the frequency and type of bathing provided, as she felt bed baths did not adequately clean her. A social services note indicated that the resident had been encouraged to communicate her needs to the nursing staff and management, but the issue persisted. A Certified Nurse Aide corroborated that the resident mostly received bed baths, highlighting a failure in the facility's responsibility to support resident self-determination and choice.
Failure to Include Spinal Cord Stimulator in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with an implanted spinal cord stimulator, which was necessary for effective pain management. The resident, who was cognitively intact and had a history of back surgeries, including a thoracic laminectomy with a paddle lead and rechargeable battery, was admitted with conditions such as type II diabetes mellitus, chronic kidney disease, obesity, and a non-pressure chronic ulcer. Despite the resident's complaints of acute and chronic pain and the presence of an indwelling medical device, the care plan did not include instructions on managing the spinal cord stimulator. The deficiency was identified during a survey when it was observed that the resident's spinal cord adapter was visible among personal items in the room, and the resident reported recharging the device himself. Interviews with the resident and staff, including the Director of Nursing and a Licensed Practical Nurse, revealed that the care plan lacked information about the spinal cord stimulator because the LPN responsible for care planning was unaware of its existence. The facility's policy required a resident-centered care plan to address all needs, but this was not adhered to in this case.
Improper Medication Storage in Medication Cart
Penalty
Summary
The facility failed to ensure that medications were stored in appropriate containers within the medication cart, which had the potential to affect three residents prescribed iron on the 500-Hall. Specifically, the medical records indicated that three residents had physician orders for ferrous sulfate 325 mg for anemia, with varying dosages and times of administration. During an observation, it was noted that the medication cart on the 500-Hall contained an unlabeled plastic medication cup with multiple green round tablets. An LPN confirmed that these pills were iron and acknowledged that they were not labeled or stored properly in the medication cart. The facility's policy on the storage of medications, dated August 2020, required that medications and biologicals be stored safely, securely, and properly according to manufacturer recommendations. This deficiency was identified during the course of a complaint investigation.
Unsanitary Food Handling by Dietary Manager
Penalty
Summary
The facility failed to ensure that food was prepared in a sanitary manner, as observed during a lunch meal preparation. Specifically, the Dietary Manager was seen touching hamburger buns with bare hands while preparing a lunch tray for a resident. During an interview, the Dietary Manager confirmed that she had used her bare hands to handle the buns and acknowledged that this was against the facility's policy. The policy, dated September 2017, required all staff to use serving utensils appropriately to prevent cross-contamination. This incident was identified during a complaint investigation.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to implement appropriate infection prevention procedures during medication administration, affecting two residents. Resident #79, who had diagnoses including major depressive disorder and mixed hyperlipidemia, was observed during medication administration. The RN administering the medication used her bare hands to pop Amlodipine and Galantamine pills from the pill card and placed them into a medication cup, even after one pill had dropped onto the medication cart. The RN confirmed during an interview that she had touched the medications with her bare hands. Similarly, Resident #63, with diagnoses including chronic diastolic congestive heart failure and stage III chronic kidney disease, was also affected. The RN administering medications for this resident used her bare hands to pop Namenda and Zoloft pills from the pill card and fished out Acetaminophen and Cyanocobalamin pills from house stock bottles. The RN admitted during an interview that she had touched multiple medications with her bare hands, contrary to the facility's policy, which states that licensed medical professionals should not touch medications during administration and should discard dropped medications.
Failure to Notify Residents of Medicaid Account Balances
Penalty
Summary
The facility failed to notify residents of their Medicaid account balances, which is a requirement to ensure residents remain within the Supplemental Security Income (SSI) resource limit. This deficiency affected three residents who were reviewed for notification of Medicaid account balances. Resident #28, who was admitted with diagnoses including schizoaffective disorder and diabetes mellitus type II, had a balance of $27,554.84, far exceeding the SSI resource limit of $2,000. Resident #29, with diagnoses of congestive heart failure and dementia, had a balance of $6,942.67. Resident #61, diagnosed with schizoaffective disorder and bladder cancer, had a balance of $16,775.66. All three residents had intact cognition and reported not receiving notification letters from the facility when their balances were within $200 of the SSI limit. The Business Office Manager confirmed that the facility did not provide written or verbal notifications to the residents when their account balances approached the SSI resource limit, which could negatively impact their Medicaid eligibility. The facility's policy, revised in 2017, mandates monthly notifications to Medicaid residents with trust fund balances nearing the SSI limit. This oversight was identified during a complaint investigation, highlighting the facility's non-compliance with its own policy and federal requirements.
Failure to Investigate and Communicate Grievance Findings
Penalty
Summary
The facility failed to properly investigate grievances and provide a summary of the findings to the residents or their representatives, affecting two residents out of three reviewed for grievances. Resident #55, who had multiple diagnoses including schizoaffective disorder and diabetes, was involved in a grievance initiated by a family member regarding care concerns attributed to a State tested Nurse Aide (STNA). Despite the grievance being filed, there was no communication from the facility regarding the investigation, findings, or resolution of the concern. Similarly, Resident #8601, who had diagnoses including a right femur neck fracture and depression, was involved in a grievance initiated by a family member concerning care provided by an STNA. The family member requested a copy of the investigation report but was informed by the Administrator that these reports only go to the State, and the results of the investigation were never provided. The Executive Director confirmed the facility's failure to investigate the concerns, complete a comprehensive written decision, and inform the residents or their representatives of the resolution.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure medications were securely stored, affecting three residents. For Resident #56, a bottle of Fluticasone Propionate was observed unsecured on the dresser in the resident's room. The resident, who has a diagnosis of schizoaffective disorder and requires supervision for daily activities, had an active physician order for the medication. An LPN confirmed that the medication should not have been left unsecured in the room. For Resident #24, three medication bottles, including Gabapentin and Hydroxyzine, were found unsecured in the resident's room. The resident, who has a history of cerebral vascular accident and other medical conditions, stated that the medications were prescribed by a psychologist and kept in the room for personal use. However, there were no physician orders for these medications in the medical record. The DON confirmed that the resident should not have prescription medications in the room. Additionally, for Resident #54, a large bottle of Betadine was found unsecured in the resident's room, despite a warning label indicating it should not be ingested. An RN verified that the bottle should not have been left in the room.
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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) |
|---|---|---|---|---|
| Courtyard At Seasons | 0.3 mi | ★★★★★ | 16 | 0 |
| Montgomery Care Center | 1.3 mi | ★★★★★ | 1 | 0 |
| Madeira Healthcare Center | 1.4 mi | ★★★★★ | 1 | 0 |
| Blue Ash Health & Rehab | 1.7 mi | ★★★★★ | 4 | 0 |
| Twin Lakes | 2 mi | ★★★★★ | 0 | 0 |
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