Below 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 Lakeridge Villa Health Care Center during CMS and state inspections, most recent first.
The facility failed to provide residents with private phone conversations, affecting two residents who had to use the phone at the nurses' station, where conversations could be overheard. Staff confirmed awareness of the issue and resident complaints, and observations showed the phone's location did not allow for privacy, contrary to the facility's dignity policy.
A facility failed to notify a resident's representative of a significant change in condition. The resident, with severe cognitive impairment and multiple diagnoses, remained in bed, refused food, and had minimal fluid intake over two days. Despite discussing a hospice referral, the facility did not inform the guardian, and the resident passed away. This was against the facility's policy requiring prompt notification of changes in medical condition.
A resident with end-stage renal disease, diabetes, and COPD was inaccurately assessed in the MDS as needing substantial assistance with daily activities, despite being independent. Interviews with the resident, a CNA, and an LPN confirmed the resident's independence, highlighting a failure to adhere to the facility's policy requiring accuracy in assessments.
A facility failed to update a care plan for a resident who was an independent smoker. Despite being assessed as able to handle smoking materials safely, the care plan did not reflect the facility's policy allowing independent smokers to keep supplies in their rooms. Observations and interviews confirmed the resident had smoking materials in his room, and the care plan was not updated to align with the new policy.
A resident with multiple diagnoses, including depression and anxiety, was prescribed Lexapro 15 mg daily. An LPN administered only 7.5 mg on 23 occasions, contrary to the physician's order. This error was confirmed during an interview with the LPN, who acknowledged the mistake. The facility's policy requires medications to be administered as prescribed, which was not followed.
A resident with specific dietary needs due to weight loss was not provided with the prescribed double portions of food as ordered by the physician. Despite the order for double portions, the resident reported receiving only small portions, which was confirmed by observation and staff interviews.
An LPN was observed serving meals with unsecured long hair, which fell into the meal trays of two residents. The residents had medical conditions such as dementia and chronic illnesses. The facility's policy mandates that staff secure their hair to prevent contact with food, which was not followed.
An LPN failed to document the administration of narcotic medications for three residents, leading to discrepancies in medication counts. The facility's policy requires documentation at the time of administration, which was not adhered to, affecting residents with various medical conditions.
The facility failed to ensure staff donned appropriate PPE when providing care to a resident under enhanced barrier precautions (EBP). Two CNAs were observed performing catheter care without wearing gowns, despite the facility's policy requiring gowns for residents on EBP. The resident had multiple medical conditions, including an indwelling catheter and active wounds, necessitating EBP.
The facility failed to provide adequate supervision during smoke breaks for two residents, leading to potential safety hazards. One resident, with multiple medical conditions and moderate cognitive impairment, was not assessed for smoking safety, while another resident, requiring supervision due to poor decision-making, was observed smoking unsupervised. The facility's policy on smoking safety was not consistently enforced, posing potential risks.
The facility failed to follow the menu and document substitutions, affecting all 90 residents who received meals. The Dietary Manager served different portions and items than those listed on the menu, did not document the substitution of English muffins for toast, and did not inform the dietitian of changes. The Director of Nursing confirmed these discrepancies.
The facility failed to maintain kitchen sanitation and ensure the dishwasher had appropriate chemical levels, with food debris found on the fryer and the dishwasher operating at zero ppm of chemical sanitizer while in use.
The facility failed to ensure residents were not provided plastic utensils with meals, affecting 46 out of 90 residents. The facility ran out of silverware and used plastic silverware for residents on the second floor, as confirmed by a dietary aide. The facility's policy states that single-service items should only be used in extenuating circumstances.
Lack of Privacy in Resident Phone Conversations
Penalty
Summary
The facility failed to ensure residents had reasonable access to and privacy in their use of communication methods, specifically phone conversations. This deficiency affected two residents, one with moderately impaired cognition and another who was cognitively intact. Both residents were required to use the phone at the nurses' station, which did not provide privacy, as conversations could be overheard by staff and other residents. Resident interviews confirmed discomfort and complaints about the lack of privacy, which were acknowledged by the staff. Observations revealed that the phone at the nurses' station was the only available option for residents to make calls, and it was positioned in a way that did not allow for private conversations. Staff interviews confirmed that they were aware of the privacy issues and had received complaints from multiple residents. The facility's policy on dignity, which emphasizes the protection of resident privacy, was not adhered to in this situation.
Failure to Notify Resident's Representative of Change in Condition
Penalty
Summary
The facility failed to notify the resident's representative of a change in condition for Resident #87, who was admitted with diagnoses including Parkinson's Disease, dementia without behavioral disturbance, and schizoaffective disorder. The Minimum Data Set (MDS) assessment indicated that the resident had severely impaired cognition and required staff assistance with activities of daily living. A progress note dated January 5, 2025, revealed that the resident had remained in bed for two days, refused food, and had minimal fluid intake. Despite these significant changes, there was no documentation that the resident's guardian was informed. An interview with the Director of Nursing confirmed that although a hospice referral was discussed due to the resident's decline, the guardian was not notified, and the resident subsequently passed away. The facility's policy required prompt notification of the resident's representative in such cases, which was not adhered to.
Inaccurate Resident Assessment in LTC Facility
Penalty
Summary
The facility staff failed to ensure the accuracy of comprehensive resident assessments, affecting one resident out of four reviewed for comprehensive assessments. The resident, admitted with diagnoses including end-stage renal disease, diabetes, and chronic obstructive pulmonary disease (COPD), was documented in the Minimum Data Set (MDS) assessment as requiring substantial to maximum assistance with toileting, bathing, and dressing. However, interviews with the resident, a CNA, and an LPN confirmed that the resident was independent in these activities and had been since admission. The LPN acknowledged that the MDS assessment was inaccurate regarding the resident's functional status. The facility policy requires all individuals completing any portion of the MDS to sign a form attesting to the accuracy of the information, which was not adhered to in this case.
Failure to Update Care Plan for Independent Smoker
Penalty
Summary
The facility failed to appropriately revise the care plan for a resident who was an independent smoker. The resident, admitted with diagnoses including rheumatoid arthritis, unspecified mental disorder, and cognitive communication deficit, was initially assessed as able to safely handle smoking materials. However, the care plan did not reflect the facility's updated policy allowing independent smokers to keep smoking supplies in their rooms. Despite the resident's ability to smoke independently, the care plan still included interventions such as securing cigarettes and lighters at the nurses' station and checking the resident's room for smoking materials. Observations and interviews revealed discrepancies between the care plan and the facility's practice. The resident was observed with smoking materials in his room, and both the resident and the Administrator confirmed that independent smokers were allowed to keep their supplies. The Director of Nursing acknowledged that the care plan had not been updated to align with the new policy, which permitted independent smokers to retain smoking supplies in their rooms. This oversight in updating the care plan led to a deficiency in the facility's compliance with its own policies and procedures.
Medication Administration Error
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically affecting one resident. The resident, who was admitted with diagnoses including encephalopathy, depression, anxiety, acute kidney failure, urine retention, and alcohol abuse, had a physician's order for Lexapro 15 mg to be administered once daily. However, during an observation of medication administration, an LPN administered only 7.5 mg of Lexapro to the resident. Upon interview, the LPN confirmed that she had consistently administered the incorrect dose of Lexapro on 23 occasions in January and February. The facility's policy on administering medications, dated April 2019, mandates that medications should be administered safely, timely, and as prescribed, which was not adhered to in this case.
Failure to Provide Prescribed Double Portions to Resident
Penalty
Summary
The facility failed to provide a resident with a diet in accordance with the physician's orders and the resident's preferences. Resident #192, who has diagnoses including diabetes, mild intellectual disability, and bilateral below the knee amputations, was admitted with an order to receive double portions of food due to weight loss. However, on 03/03/25, the resident reported receiving only small portions, which was confirmed by an observation of the dinner tray that did not contain double portions. Interviews with CNAs also confirmed that the resident received only single portions at dinner.
Improper Hair Restraint During Meal Service
Penalty
Summary
The facility failed to ensure proper hygiene practices during meal service, as observed with two residents. A Licensed Practical Nurse (LPN) was seen serving meal trays to residents with her long hair unsecured, which fell into the meal trays of two residents. The residents involved had significant medical histories, including dementia, congestive heart failure, chronic kidney disease, diabetes mellitus type two, osteoarthritis, and peripheral vascular disease. The facility's policy on preventing foodborne illness requires that all employees serving food must secure their hair to prevent contact with residents' food, which was not adhered to in this instance.
Failure to Document Narcotic Medication Administration
Penalty
Summary
The facility failed to ensure proper documentation of narcotic medication administration by nurses, affecting three residents. Resident #14, admitted with diagnoses including a right femur fracture and anxiety, had discrepancies in the Tramadol count. The controlled substance count sheet indicated three doses remaining, but observation revealed only two doses in the cart. LPN #30 confirmed administering a dose earlier in the day but had not documented it. Similarly, Resident #32, with diagnoses such as cerebral infarction and dementia, had a discrepancy in the Ativan count. The count sheet showed 12 doses remaining, but only 11 were found in the cart. LPN #30 admitted to administering a dose without documentation. Resident #67, diagnosed with cirrhosis and depression, also had a discrepancy in the Ativan count, with the count sheet showing 40 doses remaining, but only 39 were present. Again, LPN #30 confirmed administering a dose without documentation. The facility's policy requires documentation of medication administration at the time of administration, which was not followed in these instances.
Failure to Don Appropriate PPE for Resident on EBP
Penalty
Summary
The facility failed to ensure that staff donned appropriate personal protective equipment (PPE) when providing direct care to a resident under enhanced barrier precautions (EBP). This deficiency was observed during catheter care for a resident with multiple medical conditions, including unspecified quadriplegia, incomplete paraplegia, neuromuscular dysfunction of the bladder, and osteomyelitis. The resident was admitted on October 3, 2024, and was placed under EBP due to active wounds, an indwelling catheter, and a colostomy. The care plan for the resident included educating the resident and family on the use of EBP and proper PPE, as well as posting EBP signage on the resident's door. On March 5, 2025, two certified nursing assistants (CNAs) were observed providing catheter care to the resident without donning gowns, which is a requirement under the facility's EBP policy. The CNAs entered the resident's room wearing face masks and clean gloves but failed to wear gowns while transferring the resident, removing the resident's pants, emptying the catheter bag, performing catheter care, and placing a clean brief on the resident. This was confirmed in an interview with one of the CNAs, who acknowledged that neither she nor her colleague donned a gown prior to providing direct care to the resident. The facility's policy, dated August 2022, clearly states that employees should don gowns when providing care to a resident on EBP.
Inadequate Supervision During Resident Smoke Breaks
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures during smoke breaks for two residents, leading to potential safety hazards. Resident #01, who has multiple medical conditions including end-stage renal disease and moderate cognitive impairment, was not assessed for smoking safety, and their care plan lacked interventions related to smoking. Despite using tobacco, there was no evidence of a smoking assessment or restrictions, and the resident reported smoking outside designated times without staff intervention. Resident #02, diagnosed with conditions such as encephalopathy and nicotine dependence, was identified as requiring supervision during smoking due to poor decision-making and noncompliance with the smoking policy. The resident's care plan included interventions for supervised smoking and securing smoking materials, but observations revealed the resident smoking unsupervised at the facility's front entrance. Staff interviews confirmed the resident's noncompliance and the facility's challenges in enforcing the smoking policy, with staff often redirecting the resident without consistent supervision. The facility's policy mandates that residents should not possess smoking materials and must wear a smoking apron, yet these measures were not enforced for Resident #02. Interviews with staff, including the DON and Administrator, highlighted the facility's struggle to balance policy enforcement with resident independence, resulting in unsupervised smoking activities. The lack of consistent supervision and adherence to the smoking policy for both residents posed potential safety risks, as evidenced by the presence of cigarette butts and ashes at the facility's entrance.
Failure to Follow Menu and Document Substitutions
Penalty
Summary
The facility failed to ensure the menu was followed, affecting all 90 residents who received meals from the kitchen. On the morning of 05/06/24, the breakfast menu specified that residents on a regular diet were to receive six ounces of hot or cold cereal, two ounces of cheesy scrambled eggs, and one slice of toast. However, the Dietary Manager (DM) served six ounces of oatmeal, a number ten scoop of eggs, two sausage links, and a whole English muffin instead. Similarly, residents on mechanical and pureed diets received different portions and items than those listed on the menu. The substitution of English muffins for toast was not documented in the substitution log, and the dietitian was not informed of this change. Additionally, the DM used incorrect scoop sizes due to missing equipment and made unauthorized changes to the menu by adding sausage links for additional protein variety. During the tray line, the DM also altered the portion sizes of English muffins partway through service, serving only one half or one slice to some residents due to concerns about running out of English muffins. The Director of Nursing (DON) confirmed these discrepancies and the lack of documentation for the substitutions. The facility's Substitutions policy, dated April 2007, states that the food service manager, in conjunction with the dietitian, may make food substitutions as appropriate and necessary, and all substitutions must be noted on the menu and filed according to established dietary policies. The failure to follow the menu, document substitutions, and inform the dietitian of changes led to the deficiency. This affected the nutritional intake and consistency of meals provided to the residents, as the portions and items served did not align with the planned menu or dietary requirements.
Sanitation and Dishwasher Chemical Levels Deficiency
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary manner and ensure the dishwasher had the appropriate level of chemicals to prevent foodborne illness. During an observation of the kitchen, food debris was found built up in the oil and on the edges of the fryer, as well as on the fryer basket. Additionally, there was brown splatter on the side of the fryer and brown water on the floor of the kitchen near the steam table where food was served. The Dietary Manager confirmed these observations during an interview. Further observation revealed that the dishwasher's temperature was 125 degrees Fahrenheit for both the wash and rinse cycles, and the chemical levels tested at zero parts per million (ppm). Despite this, dietary staff were observed actively running dishes through the dishwasher. The Dietary Manager verified that the dishwasher required chemicals to sanitize the dishes and confirmed that it was operating with zero ppm of chemical sanitizer while in use. The facility's Food Preparation and Service policy, dated November 2022, mandates that all food service equipment and utensils be sanitized according to current guidelines and manufacturer instructions.
Use of Plastic Utensils Due to Silverware Shortage
Penalty
Summary
The facility failed to ensure residents were not provided plastic utensils with meals, affecting 46 out of 90 residents. On the morning of May 6, 2024, during an observation of the tray line, it was revealed that the facility ran out of silverware and resorted to using plastic silverware for residents on the second floor. This was confirmed by an interview with a dietary aide who verified the shortage of silverware. The facility's policy on disposable dishes and utensils, dated November 2007, states that single-service items should only be used in extenuating circumstances such as dish machine failure, individual resident needs and requests, or other documented reasons. This deficiency was investigated under Master Complaint Number OH00153346.
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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) |
|---|---|---|---|---|
| Mt Airy Gardens Rehabilitation And Nursing Center | 0.7 mi | ★★★★★ | 2 | 0 |
| Ohio Living Llanfair | 1.7 mi | ★★★★★ | 4 | 0 |
| Clovernook Health Care And Rehabilitation Center | 2 mi | ★★★★★ | 27 | 0 |
| Covenant Village Care Center | 2.3 mi | ★★★★★ | 6 | 0 |
| Twin Towers | 2.3 mi | ★★★★★ | 3 | 0 |
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