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 Laurels Of Huber Heights The during CMS and state inspections, most recent first.
A facility failed to ensure dependent residents received timely bathing and personal hygiene assistance. One resident missed multiple showers and reported going over a week without one, another had no documentation of any bath or shower during the stay, and a third resident was observed with facial hair that had not been shaved despite needing substantial to maximum help with personal hygiene.
A cognitively intact resident with multiple comorbidities, including ESRD on dialysis and an infected back surgical wound, experienced a change in wound status with purulent and bloody drainage documented by nursing staff. Wound care was provided per existing orders, but the RN did not document notifying the physician or the resident’s representative of this new development. The wound physician later reported being unsure if he had been notified, and the DON confirmed that no notification was recorded, despite facility policy requiring practitioner and representative notification for changes in status.
Two residents admitted with significant wounds did not receive timely wound assessments or prompt initiation of treatment. In both cases, initial nursing assessments lacked measurements and detailed descriptions of wounds, and comprehensive evaluations were delayed by several days. Although physician orders for wound care were eventually obtained and treatments administered, the facility did not follow its policy requiring immediate documentation and intervention for skin impairments upon admission.
A resident with multiple comorbidities was admitted with several skin impairments, but the facility did not complete a full pressure ulcer assessment or initiate wound treatment in a timely manner. Documentation showed that wounds were not measured or described upon admission, and treatment was delayed until several days later, contrary to facility policy requiring prompt evaluation and intervention.
An LPN was observed handling oral medications with bare hands before administering them to a resident with multiple chronic conditions. This action was not in accordance with the facility's infection control and medication administration policies, which require hand hygiene and prohibit direct hand contact with medications.
Two residents receiving TPN had their Medication Administration Records signed by LPNs, despite TPN administration being outside the LPN scope of practice. Interviews confirmed LPNs did not administer the TPN but documented as if they had, contrary to facility policy and state regulations.
Staff did not follow enhanced barrier precautions during wound care for a resident with multiple wounds and severe cognitive impairment. Despite clear signage and care plan instructions requiring the use of gloves and gowns for high-contact care, an LPN, a CNA, and a wound physician performed wound care activities without donning gowns. All involved staff later acknowledged the lapse, and the DON confirmed the absence of proper PPE storage outside the room.
A resident with multiple health conditions and severe cognitive impairment was assessed as an unsafe smoker and expressed a desire to smoke. The facility's policy required supervision for unsafe smokers, but the DON confirmed that no supervised smoking was offered, effectively prohibiting the resident from smoking. This was contrary to the facility's policy, leading to a deficiency in honoring the resident's smoking rights.
The facility failed to follow its abuse policy by not reporting allegations of abuse and neglect in a timely manner, not suspending accused staff, and delaying investigations. A resident with quadriplegia reported aggressive behavior by a nurse, and another resident was involved in an allegation of medication withholding. The facility did not document staff education on abuse prevention, contrary to its policy.
The facility failed to report allegations of abuse to the state agency in a timely manner, affecting two residents. One resident reported concerns about staff behavior, including an incident with a nurse described as aggressive. Despite a complaint from the insurance company, no investigation was initiated. Another resident was involved in an incident where a nurse allegedly threatened to withhold medications, but the investigation was delayed. The facility did not adhere to its policy on abuse prohibition, resulting in a deficiency.
The facility failed to conduct timely investigations and protect residents during abuse allegations. A resident reported concerns about staff behavior, including an incident with a nurse, but the facility did not initiate an investigation or suspend the accused nurse. Another resident was involved in an incident where a nurse allegedly threatened to withhold medications, but the facility delayed the investigation. The facility did not follow its policy requiring immediate investigation and suspension of accused staff.
A resident with severe cognitive impairment, assessed as an unsafe smoker, was able to access and smoke a lit cigarette butt unsupervised, resulting in a small burn on their thigh. The facility's policy required supervision and control of smoking materials for unsafe smokers, but the resident's behavior of seeking cigarette butts led to the incident, indicating a lapse in supervision.
A facility failed to document a crucial phone call in a resident's medical record. The call involved allegations from a former roommate that a nurse threatened to withhold medications. The social worker confirmed the call but did not document it or ask further questions.
A facility failed to maintain appropriate enhanced barrier precautions (EBP) and hand hygiene during wound and incontinence care for a resident with an unstageable pressure ulcer. Staff did not don gowns or change gloves as required by facility policy, leading to a deficiency. Interviews confirmed the lack of adherence to EBP and hand hygiene protocols.
The facility failed to maintain adequate water temperatures in the shower rooms on the 400 hall, with temperatures not reaching the required 105 degrees Fahrenheit, potentially affecting 42 residents. Observations and logs confirmed that water temperatures consistently remained below the required level since October 2024. The issue was acknowledged by the Administrator and Maintenance Director, who confirmed that a local plumbing company was contracted to address the problem.
A resident with moderate cognitive impairment and an indwelling urinary catheter experienced a delay in response to a call light, which was on for 22 minutes without being addressed by staff. The resident had activated the call light due to concerns with a leaking catheter. The facility's policy requires timely response to call lights, which was not followed in this instance.
A resident with type two diabetes, vascular dementia, and glaucoma was unable to reach her call light, which was found behind a dresser by an LPN. The resident reported it had been out of reach all night. The facility's policy requires call lights to be within reach, which was not followed, leading to a deficiency finding.
A resident with multiple health issues developed a large blister on their leg, and while the Nurse Practitioner was informed, the family was not notified, contrary to the facility's policy. Interviews confirmed the lack of documentation for family notification.
A resident with severe cognitive impairment was found with a bruise and later a black eye, with no clear explanation for the injuries. Despite reports from hospice RN and STNA, the facility failed to notify the Ohio Department of Health as required by their abuse policy. The investigation suggested the resident may have hit her face on a chair, but the facility did not file a Self-Reported Incident (SRI) or assess other cognitively impaired residents for similar injuries.
A resident with severe cognitive impairment was found with a bruise of unknown origin, and the facility failed to conduct a thorough investigation or protect the resident from potential abuse. The investigation did not include interviews with other staff or assessments of other residents, and the incident was not reported as required by facility policy.
Failure to Provide Timely ADL Assistance and Personal Hygiene Care
Penalty
Summary
The facility failed to ensure residents who were dependent on staff for activities of daily living received timely and adequate assistance with personal hygiene and bathing. Resident #1, who had diagnoses including acute respiratory failure, anxiety disorder, type II diabetes mellitus, and pneumonia, was assessed as having intact cognition and requiring substantial assistance with bathing. Review of the ADL task log showed missed showers on multiple dates in April and May 2026, and the resident reported on 05/17/26 that she had not had a shower in over a week, had once received a shower at midnight, and had been unable to sleep because her hair was wet and she was cold. The DON later verified the missed showers and stated the resident's showers would be changed to days. Resident #95, who had diagnoses including nontraumatic intracerebral hemorrhage, muscle wasting and atrophy, hemiplegia and hemiparesis following cerebral infarction, and heart disease, was assessed as having moderate cognitive impairment and being dependent on staff for bathing. There was no documentation that the resident was offered or received a shower or bath during the stay, and no documentation of refusal. Resident #9, who had diagnoses including end stage renal disease, type II diabetes mellitus, and heart failure, was assessed as requiring substantial to maximum assistance with personal hygiene. On observation, the resident had gray facial hairs on the chin and jawline and stated she was bothered by them and wanted them shaved; a CNA confirmed the facial hair was present. The facility policy stated residents should receive necessary assistance to maintain grooming and personal/oral hygiene, including daily face and hand washing, shaving, nail care, hair combing, and tooth brushing.
Failure to Notify Physician and Representative of Change in Wound Status
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely notification of a physician and resident representative when a resident’s wound status changed. The resident was admitted with multiple diagnoses including spinal stenosis, end-stage renal disease on dialysis, anemia, and type 2 diabetes, and had an infected back surgical wound and an infected finger awaiting amputation. The admission MDS showed the resident was cognitively intact and required varying levels of assistance with ADLs while using a wheelchair. The care plan included monitoring for complications related to end-stage renal disease and infection. Progress notes from the wound nurse documented an infected back surgical wound and, on a later date, a large amount of bloody/purulent drainage from the back wound, with the wound cleansed, packed with Iodoform gauze, and dressed per treatment orders. A subsequent physician order directed daily and PRN wound care to the lower back, including cleansing with normal saline, packing with Iodoform gauze, and covering with a dry dressing. On a later date, an RN documented purulent drainage from the back wound and that the dressing was changed per the physician’s order, but there was no documentation that the physician or family were notified of this change in the wound’s condition. The wound physician later stated he was unsure if he had been notified about pus or drainage from the thoracic surgery site and indicated he would not have changed treatment until he returned to the facility. The DON confirmed that the RN had not notified a physician or the family in the progress note and stated she would have expected at least notification of the on-call physician for any new development. The RN could not recall whether she had notified the physician or family and verified that no such notification was documented. Facility policy required informing the resident, consulting with the practitioner, and notifying the resident representative when there was a change in status, including significant changes in health status.
Failure to Timely Assess and Initiate Treatment for Wounds Upon Admission
Penalty
Summary
The facility failed to complete wound assessments at the time of admission and did not timely initiate treatment for wounds for two out of three residents reviewed. For one resident with multiple medical conditions including diabetes, peripheral vascular disease, and a recent amputation, the admission assessment noted several skin issues but did not include measurements or detailed descriptions. Comprehensive wound evaluations were not completed until five days after admission, and physician-ordered treatments were not initiated until six days after admission. The resident was subsequently seen weekly by a wound physician, but initial documentation and intervention were delayed. Another resident admitted with a history of diabetes and chronic foot ulcers also did not have wound measurements or descriptions documented at admission, despite having visible surgical wounds. Although a physician order for wound care was obtained the day after admission and treatments were administered as ordered, the wounds were not measured or fully assessed until five days post-admission. Staff interviews confirmed the lack of timely wound assessment and documentation. Facility policy required baseline total body skin evaluations and prompt documentation of wound characteristics and interventions upon admission, which was not followed in these cases.
Failure to Timely Assess and Treat Pressure Ulcers on Admission
Penalty
Summary
The facility failed to complete pressure ulcer assessments upon admission and did not timely initiate treatment for pressure ulcers for one resident. Upon admission, the resident had multiple medical diagnoses, including aftercare following surgical amputation, peripheral vascular disease, end stage renal disease, and diabetes mellitus. The initial nursing comprehensive assessment documented the presence of a right toe amputation and redness to the buttocks, coccyx, and heels, but did not include measurements or detailed descriptions of these skin issues. Wound and skin evaluations were not completed until five days after admission, at which point multiple wounds were identified and measured, including vasculitic injuries, deep tissue injuries (DTIs), and moisture-associated skin damage. However, there was no documentation that treatment for these wounds was initiated until the day after the evaluation was completed. Staff interviews and policy review confirmed that the facility's policy required a baseline total body skin evaluation and prompt initiation of appropriate interventions and physician orders for any skin impairments upon admission. The medical record lacked evidence that these requirements were met for the resident in question, as wounds were not evaluated or treated in a timely manner. The deficiency was identified during a complaint investigation and was based on the facility's failure to follow its own skin management policy for new admissions with existing skin impairments.
Failure to Follow Infection Control Procedures During Medication Administration
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to follow infection control procedures during medication administration for a resident with multiple medical diagnoses, including cerebral infarction, dysphagia, vascular dementia, hypertension, and diabetes mellitus. The LPN was observed preparing medications by placing aspirin, Oyster Calcium, and senna tablets directly into her bare hands before transferring them into a medication cup. The medications were then crushed and mixed with applesauce prior to administration to the resident. During an interview, the LPN confirmed that she had handled the medications with her bare hands. Review of the facility's medication administration policy revealed that staff are required to perform hand hygiene before medication preparation and avoid touching the inside of medication cups or medications with bare hands. The policy also states that any medication coming into contact with bare hands should be disposed of and replaced. The observed actions were not in accordance with the facility's policy, resulting in a deficiency finding.
Improper Documentation and Administration of TPN by LPNs
Penalty
Summary
The facility failed to ensure that the administration of total parenteral nutrition (TPN) was completed in accordance with professional standards of practice, specifically regarding the roles and responsibilities of nursing staff. Medical record reviews for two residents with complex medical histories, including surgical aftercare, intestinal fistulas, colostomy status, protein-calorie malnutrition, and lymphoma, revealed that TPN was ordered and administered over several months. Both residents had care plans and physician orders specifying TPN administration, with instructions for registered nurses (RNs) to mix and manage the TPN solutions. However, review of the Medication Administration Records (MAR) showed that licensed practical nurses (LPNs) repeatedly signed off on the administration of TPN for both residents. Interviews with the Director of Nursing (DON) and LPNs confirmed that LPNs did not actually administer the TPN but signed the MAR as if they had, sometimes indicating that they were signing off for the RNs. The DON and LPNs acknowledged that LPNs are not permitted to initiate or maintain TPN, as it is outside their scope of practice according to the Ohio Revised Code. Facility policy review confirmed that only licensed nursing staff authorized by state law should prepare, administer, and record medications, and that LPNs are specifically prohibited from initiating or maintaining TPN. The deficiency was identified through a combination of medical record review, staff interviews, and policy review, and it affected two of three residents reviewed for IV administration.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Staff failed to implement enhanced barrier precautions during wound care for a resident with multiple complex medical conditions, including cerebral infarction, heart failure, end stage renal disease, type two diabetes, and severe vascular dementia. The resident required extensive assistance with activities of daily living and had several wounds requiring dressings, as documented in the care plan and active physician orders. The care plan specifically included enhanced barrier precautions as an intervention for skin impairment. Signage outside the resident's room indicated that enhanced barrier precautions were required, including the use of gloves and gowns for high-contact care activities such as wound care. During an observed wound care session, an LPN, a CNA, and a wound physician entered the resident's room and performed wound care activities, including removing and applying dressings, without donning gowns as required by the enhanced barrier precautions protocol. All three staff members later confirmed in interviews that they did not wear gowns and acknowledged that the resident was supposed to be under enhanced barrier precautions. The Director of Nursing also confirmed the lack of appropriate personal protective equipment storage outside the resident's room at the time of the incident.
Failure to Honor Resident Smoking Rights
Penalty
Summary
The facility failed to honor the smoking rights of a resident who was assessed as an unsafe smoker. The resident, who had a history of cerebrovascular accident, coronary artery disease, viral hepatitis, dementia, seizure disorder, and diabetes, was admitted to the facility and expressed a desire to smoke. Despite being severely cognitively impaired and requiring assistance for daily activities, the resident was found to be seeking cigarette butts and asking other residents for cigarettes. The care plan indicated that the resident was to be supervised while smoking, and the facility's policy required staff to maintain smoking paraphernalia and supervise unsafe smokers. However, the Director of Nursing confirmed that the facility did not offer supervised smoking for residents assessed as unsafe smokers, effectively prohibiting the resident from smoking on the facility grounds. This was contrary to the facility's smoking policy, which stated that unsafe smokers should be supervised and provided with smoking materials at designated times. The resident, when interviewed, was unaware of the reasons for being prohibited from smoking, indicating a lack of communication and adherence to the facility's policy on resident rights and smoking supervision.
Failure to Report and Investigate Abuse Allegations
Penalty
Summary
The facility failed to adhere to its abuse policy in several instances, leading to deficiencies in handling allegations of abuse and neglect. For Resident #87, the facility did not report an allegation of neglect to the state agency in a timely manner. The resident, who was cognitively intact and required assistance with activities of daily living, expressed concerns about staff behavior, including an incident with a wound nurse described as physically aggressive. Despite these concerns, the facility did not initiate a Self-Reported Incident (SRI) for the complaint received from the insurance company, nor did they suspend the accused nurse pending investigation. In another case involving Resident #61, who was moderately cognitively impaired, the facility delayed initiating an investigation into allegations that a nurse threatened to withhold medication. The allegation was reported by a hospital social worker to the facility's social worker, who then informed the Administrator. However, the facility did not begin the investigation until several days later, and the resident was not interviewed until even later. This delay in response was contrary to the facility's policy, which mandates immediate investigation and reporting of such allegations. The facility's policy requires that all staff be educated on abuse prevention and that any allegations be thoroughly investigated and reported. However, the facility failed to document staff education on abuse prevention following the investigation of Resident #87's case. Additionally, the facility did not suspend the accused staff member during the investigation, as required by their policy. These failures highlight significant lapses in the facility's adherence to its own abuse prevention and reporting protocols.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse to the state agency in a timely manner, affecting two residents. Resident #87, who was cognitively intact and required assistance with activities of daily living, reported concerns about staff behavior, including an incident with a wound nurse, RN #131, whom the resident described as physically aggressive and abusive in language. Despite receiving a complaint from the resident's insurance company, the facility did not initiate a Self-Reported Incident (SRI) or conduct an investigation into these concerns, as the Administrator did not believe there was enough information to identify abuse. RN #131 was not informed of the allegations, nor was she suspended pending an investigation. Resident #61, who was moderately cognitively impaired and required assistance with activities of daily living, was involved in another incident where a hospital social worker reported that a former roommate alleged a facility nurse threatened to withhold medications. The facility delayed initiating an investigation and interviewing Resident #61, starting the process eight days after the initial report. The Social Worker, SW #87, did not document the phone call from the hospital social worker in the resident's record and only reported it to the Administrator the following day. The facility's policy on abuse prohibition requires that all allegations of abuse, neglect, or mistreatment be thoroughly investigated and reported to the appropriate state agencies. However, in both cases, the facility did not adhere to this policy, resulting in a deficiency. The Administrator confirmed the lack of timely investigation and reporting in both incidents, which were not aligned with the facility's established procedures for handling such allegations.
Failure to Investigate and Protect Residents During Abuse Allegations
Penalty
Summary
The facility failed to conduct timely and thorough investigations and did not protect residents during abuse investigations by suspending accused staff. This deficiency affected two residents. Resident #87, who was cognitively intact and required assistance with activities of daily living, reported concerns about staff behavior, including an incident with a wound nurse who was allegedly physically aggressive and abusive in language. Despite these allegations, the facility did not initiate a Self-Reported Incident (SRI) regarding the complaint from the insurance company, nor did they suspend the accused nurse pending investigation. The facility also lacked documentation of staff education on abuse and neglect prevention. Resident #61, who was moderately cognitively impaired and required assistance with activities of daily living, was involved in another incident where a former roommate alleged that a facility nurse threatened to withhold medications. The facility delayed initiating an investigation into this allegation, waiting eight days after being informed by a hospital social worker. The facility did not interview Resident #61 until nine days after the initial report. The facility's policy required immediate suspension of accused staff and thorough documentation and investigation of abuse allegations, which was not followed in this case. The facility's failure to adhere to its Abuse Prohibition Policy, which mandates immediate investigation and suspension of accused staff, resulted in noncompliance. The policy also required staff to be educated on abuse prevention, which was not documented. These deficiencies were investigated under Complaint Number OH00161688, highlighting the facility's inadequate response to abuse allegations and failure to protect residents during investigations.
Failure to Supervise Unsafe Smoker Leads to Incident
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents involving a resident who was identified as an unsafe smoker. The resident, who had a history of severe cognitive impairment and required assistance with daily activities, was assessed as unsafe to smoke due to an inability to handle smoking materials safely. Despite this assessment, the resident was able to access cigarette butts and smoke unsupervised, leading to an incident where the resident's clothing caught fire, resulting in a small reddened area on the resident's thigh. The facility's policy required that unsafe smokers be supervised and wear protective gear while smoking, and that staff maintain control of all smoking materials. However, the resident was able to obtain a lit cigarette butt, indicating a lapse in supervision and control of smoking materials. Interviews with staff confirmed that the resident had a behavior of seeking out cigarette butts and that the incident occurred when the resident was unsupervised, highlighting a failure to adhere to the facility's smoking policy and ensure the resident's safety.
Incomplete Medical Record Documentation
Penalty
Summary
The facility failed to maintain a complete medical record for a resident, which is a deficiency in safeguarding resident-identifiable information and maintaining medical records according to professional standards. A review of the medical record for a resident, who was admitted with diagnoses including occlusion and stenosis of the right carotid artery and diabetes, revealed a lack of documentation regarding a phone call from a hospital social worker to the facility's social worker. This call, which occurred on January 15, 2025, involved allegations made by a former roommate of the resident, claiming that a facility nurse had threatened to withhold the resident's medications. The facility's social worker confirmed the call took place but admitted to not documenting it in the resident's medical record, nor did she inquire further into the allegations.
Failure to Maintain Enhanced Barrier Precautions and Hand Hygiene
Penalty
Summary
The facility failed to ensure staff maintained appropriate enhanced barrier precautions (EBP) and hand hygiene during wound care and incontinence care for Resident #23. The resident, who was admitted with diagnoses including a fracture of the superior rim of the left pubis, heart failure, and atrial fibrillation, had an unstageable pressure ulcer on the buttock. Despite the presence of this wound, there were no physician's orders for EBP for the resident. During an observation, a registered nurse and a certified nursing assistant did not don gowns prior to providing wound care, and the CNA did not change gloves during or after incontinence care, using soiled gloves to touch various objects in the resident's room. Interviews with the CNA and RN confirmed the lack of gown use during care and improper glove use. The facility's policy on EBP indicated that residents with wounds should have EBP in place, requiring staff to wear gloves and gowns during high-contact care. Additionally, the facility's hand hygiene policy emphasized the importance of hand washing before and after resident contact and after removing personal protective equipment. The failure to adhere to these policies resulted in the deficiency noted in the report.
Failure to Maintain Adequate Water Temperatures in Shower Rooms
Penalty
Summary
The facility failed to ensure that water temperatures in the shower rooms on the 400 hall reached a comfortable level for residents, specifically not reaching the required 105 degrees Fahrenheit. Observations revealed that the water temperatures in the shower stalls only reached a maximum of 90 degrees Fahrenheit. This issue was confirmed by the Maintenance Director, who denied any recent hot water concerns despite the documented evidence. The deficiency was noted to potentially affect 42 residents residing on the 300 and 400 halls, as these residents used the 400 hall shower room. Review of the facility's water temperature logs showed that the hot water temperatures had consistently been below 105 degrees Fahrenheit since October 2024. Specific temperatures recorded included 89 degrees Fahrenheit on December 17, 2024, 90 degrees Fahrenheit on December 16, 2024, and 88 degrees Fahrenheit on December 10, 2024. The Administrator and Maintenance Director acknowledged the ongoing hot water issues and confirmed that a local plumbing company had been contracted to address the problem. This deficiency was investigated under Complaint Numbers OH00160422 and OH00160868.
Failure to Timely Respond to Resident Call Light
Penalty
Summary
The facility failed to ensure timely response to a resident's call light, affecting one resident out of six reviewed for call light responsiveness. The resident, who had been admitted with diagnoses including type two diabetes mellitus, hypertension, major depressive disorder, and acute kidney failure, was observed with a call light on for 22 minutes without being addressed by staff. The resident had moderate cognitive impairment, was frequently incontinent of bowel, and had an indwelling urinary catheter. During the observation, a Licensed Practical Nurse (LPN) was seen sitting at the nurse's station and later walking past the resident's room without addressing the call light. The resident had activated the call light due to concerns with a leaking urinary catheter and expressed that call lights often take a while to be answered. The facility's policy requires call lights to be answered in a timely manner, which was not adhered to in this instance. The Administrator confirmed that the delay in response was not timely and that any staff member, including the LPN, should have addressed the call light. This deficiency was investigated under a specific complaint number.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a resident's call light was kept within reach, affecting one of six residents reviewed for call lights. The resident, who was admitted with diagnoses including type two diabetes mellitus, vascular dementia, and glaucoma, was found to be cognitively intact according to a significant change Minimum Data Set (MDS) assessment. During an observation, an LPN asked the resident to use her call light for assistance, but the resident was unable to find it and stated it had been out of reach all night. The LPN discovered the call light behind a dresser drawer cabinet, confirming it was not within the resident's reach. The facility's policy requires call lights to be within a resident's reach, which was not adhered to in this instance. This deficiency was investigated under Complaint Number OH00160868.
Failure to Notify Family of Resident's Health Change
Penalty
Summary
The facility failed to notify the family of Resident #90 about a significant change in the resident's health status, specifically regarding impaired skin integrity. Resident #90, who had diagnoses including gram-negative sepsis, congestive heart failure, a non-pressure chronic ulcer of the left lower leg, and renal disease, was noted to have a large intact blister on the calf of the right leg on 04/29/24. The staff notified the Nurse Practitioner, who ordered the wound care physician to see the resident. However, there was no documentation of family notification regarding this change in condition. Interviews with the Licensed Practical Nurse and the Director of Nursing confirmed the absence of documentation related to family notification about the blister. The facility's policy on Change of Condition Notification, dated 02/14/2024, requires notifying the resident's representative of changes in condition, including deterioration in health. This deficiency was identified during an investigation under Complaint Number OH00154584.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to notify the Ohio Department of Health (ODH) of an injury of unknown origin involving a resident, which is a requirement under their abuse policy. The incident involved a resident with severe cognitive impairment and multiple health conditions, including heart disease and dementia. The resident was found with a bruise on the right cheek, and later a black eye, with no clear explanation for the injuries. The hospice RN and a State tested Nursing Assistant (STNA) reported the bruising to the Unit Manager (UM), but the facility did not file a Self-Reported Incident (SRI) as required. The investigation into the incident revealed that the resident was agitated during care, and it was suggested that the resident may have hit her face on a chair. However, the facility's Director of Nursing (DON) and UM did not consider the bruising as an injury of unknown origin that needed to be reported. Additionally, there was no assessment of other cognitively impaired residents for similar injuries. The facility's policy mandates that such incidents be reported to the state agency within a specific timeframe, which was not adhered to in this case.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin and did not protect a resident from potential abuse. Resident #10, who was severely cognitively impaired and required assistance for mobility and personal care, was found with a bruise on the right cheek by a hospice RN. The origin of the bruise was unknown, and the incident was not reported as a Self-Reported Incident (SRI). The facility's investigation was incomplete, as it did not include interviews with other staff who might have had knowledge of the incident, nor did it assess other cognitively impaired residents for similar injuries. The Director of Nursing confirmed that the facility did not initiate a full abuse investigation related to the bruising, and the Unit Manager did not consider filing an SRI. The facility's policy requires thorough investigation of abuse allegations, including injuries of unknown origin, and protection of residents during investigations. However, the investigation did not include measures to protect the resident or education of other staff. The deficiency was identified under Complaint Number OH00154913.
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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 Huber Heights
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Momentous Health At Vandalia | 2 mi | ★★★★★ | 19 | 0 |
| Stonespring Of Vandalia | 4.9 mi | ★★★★★ | 0 | 0 |
| Riverside Nursing And Rehabilitation Center | 6.2 mi | ★★★★★ | 21 | 1 |
| Siena Woods Care Center | 6.6 mi | ★★★★★ | 14 | 0 |
| Aventura At Carriage Inn | 6.8 mi | ★★★★★ | 13 | 0 |
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