Below average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Laurels Of West Carrollton The during CMS and state inspections, most recent first.
Ordered antipsychotic medication was not administered to a resident with bipolar disorder, depression with psychotic features, DM, paranoid schizophrenia, and HTN. An RN gave the resident other scheduled meds but stated Risperdal was unavailable from pharmacy, and the DON confirmed there was no MAR documentation that it was given as ordered, the physician was not notified, and the med was available in the emergency locked box.
Infection Control Lapses During Medication Administration: Two residents were involved in medication administration errors tied to infection control. An RN placed oral meds into bare hands before putting them in a medication cup for one resident, and during insulin administration for another resident, the RN did not perform hand hygiene or apply gloves and used a vial of Lispro instead of the ordered kwikpen. The residents had multiple chronic conditions, including DM, psychiatric diagnoses, heart failure, and pulmonary hypertension.
A resident with multiple comorbidities and a documented fall risk experienced a mechanical fall when a bedside commode, which had been taped and was mechanically unstable, collapsed while in use, causing the resident to fall through and become stuck. Staff documentation and interviews confirmed that the commode’s bucket-support bar had been taped with surgical tape and failed under the resident’s weight, and that the equipment was not sturdy. Although an LPN completed a fall packet noting equipment malfunction and the commode being taped together, management did not obtain statements from involved CNAs or the LPN about who altered or placed the commode in the room, and there was no thorough investigation into which staff member taped the commode or how the unsafe equipment came to be used, despite a facility policy requiring IDT review and investigation of all falls.
A resident with Alzheimer’s disease, CHF, metabolic encephalopathy, an unstageable sacral pressure ulcer, and essential tremor, who had impaired cognition and required staff assistance with eating, toileting hygiene, bed mobility, and transfers, did not have weights monitored according to the facility’s Weight Management policy. The policy required weights on admission, weekly for four weeks, and then monthly, but documentation showed only three weights were obtained, with no further weights recorded before the resident was transferred to the hospital. The UM confirmed both the policy requirements and the absence of additional documented weights, resulting in a cited deficiency for failure to follow the facility’s weight-monitoring protocol.
A CNA entered and cleaned the room of a resident on contact and droplet isolation for COVID-19 without wearing PPE, despite posted signage and facility policy requiring PPE for all staff entering isolation rooms. The CNA was unsure if PPE was needed for housekeeping duties, leading to noncompliance with infection control protocols.
A nurse crushed and administered extended-release Potassium Chloride and delayed-release Omeprazole to a resident with multiple chronic conditions, despite both medications being on the facility's 'Do Not Crush' list and contrary to FDA guidance and facility policy.
A resident with a history of intracranial hemorrhage, COPD, and anxiety disorder was allowed to keep an albuterol inhaler at their bedside without a documented assessment or physician order for self-administration, as required by facility policy. Staff were aware of the medication at the bedside but did not follow the established process, and the care plan did not reflect self-administration authorization.
Three residents had care plans that did not accurately reflect their assessed smoking status or required supervision, with documentation indicating supervision was needed when evaluations and staff confirmed some could smoke independently and another was unsafe to smoke. Staff interviews revealed reliance on unedited, self-populated care plan templates, resulting in care plans that did not match current assessments or facility policy.
A resident with a history of malnutrition and dysphagia had a care plan that was not updated to reflect a change from NPO status to a pureed diet with honey thickened liquids. Despite new dietary orders and the resident being observed eating a pureed diet, the care plan continued to reference NPO status and tube feeding. Staff interviews confirmed that care plans should be updated in real time, but this did not occur, resulting in outdated information remaining in the resident's care plan.
A resident with hemiplegia, hemiparesis, diabetes, and chronic kidney disease did not receive required nail care, as their fingernails were observed to be long and untrimmed on multiple occasions. Facility policy and the care plan required regular nail care, and staff interviews confirmed that only nurses could trim nails for diabetic residents. Despite these requirements, the resident's nails were not trimmed as expected.
A resident with intact cognition and a history of respiratory conditions was found with multiple prescription and OTC medications at their bedside, despite not being assessed or authorized for self-administration. Facility staff confirmed that medications are not permitted in resident rooms without proper authorization, and the care plan did not reflect self-administration. The medications remained accessible to the resident for several weeks without staff awareness, in violation of facility policy.
A resident with severe cognitive impairment and an indwelling Foley catheter was observed to have their catheter tubing unsecured during care, resulting in repeated tugging on the tubing by staff. Despite care plan interventions requiring the tubing to be anchored to prevent trauma, staff confirmed that no anchor was in place since the resident's return from the hospital, and the DON expected all such residents to have an anchor.
A resident with diabetes and severe cognitive impairment was administered insulin glargine on two occasions when their blood sugar was below the physician-ordered threshold. Staff failed to follow the specific order to withhold insulin if blood sugar was under 140, resulting in a significant medication error despite facility policy and leadership expectations.
Staff failed to follow Enhanced Barrier Precautions during wound care for a resident with an indwelling catheter and unhealed pressure ulcers. Two LPNs provided wound treatment using gloves but did not wear gowns, despite facility policy and care plan directives. Interviews revealed staff were aware of EBP requirements but did not adhere to them during the observed care.
The facility did not complete or document required smoking assessments for three residents who used tobacco, failing to follow its own policy for evaluation upon admission, readmission, and at regular intervals. Staff interviews and record reviews showed that assessments were missing or incomplete, and some staff were unaware of the policy's requirements.
A resident with moderate cognitive impairment was admitted with a significant sum of money, which was counted and placed in a medication cart's narcotic drawer by staff. The money was later found missing, and despite staff interviews and an internal investigation, the funds were never recovered. The facility failed to safeguard the resident's property as required by policy.
A resident with moderate cognitive impairment was admitted with a significant amount of money, which was placed in a medication cart's narcotic drawer by staff. The money later went missing, and although staff became aware of the loss, the incident was not reported to the state survey agency within the required timeframe. Facility policy required prompt reporting of such allegations, but the delay was confirmed through documentation and staff interviews.
A resident with moderate cognitive impairment was admitted with a significant amount of money, which was placed in a double-locked medication cart drawer by an LPN. The money was later discovered missing, and although several staff had access to the cart during the relevant period, most were not interviewed as part of the investigation. The facility's policy required a thorough investigation, but this was not completed, as acknowledged by the DON and Administrator.
A facility failed to report an allegation of sexual abuse involving a resident with severely impaired cognition to the state agency, as required by their policy. The resident, who required extensive assistance for daily activities, was discharged against medical advice. A hospital evaluation later revealed the abuse allegation, which was reported to the police and Ombudsman. The facility's Administrator acknowledged the failure to file a self-reported incident (SRI) with the state agency, resulting in a deficiency citation.
A facility failed to investigate an allegation of sexual abuse involving a resident with severely impaired cognition. The resident, who required extensive assistance, was discharged against medical advice and later reported an abuse allegation during a hospital evaluation. The facility's Administrator did not conduct a thorough investigation as per policy, only verbally questioning male staff without obtaining written statements or documentation.
The facility failed to accurately transcribe and administer medications for a resident upon admission, resulting in multiple medication omissions and errors. The resident did not receive Atenolol and Lidocaine Patch EX for several days, and there were transcription errors for Buprenorphine HCl-Naloxone HCl and Alendronate Sodium. These issues were confirmed through medical record reviews and staff interviews.
Ordered antipsychotic medication was not administered
Penalty
Summary
Pharmaceutical services failed to meet the needs of Resident #62 when ordered Risperdal 0.5 mg was not administered as prescribed. Resident #62 was admitted with diagnoses including bipolar disorder, depression with psychotic features, DM, paranoid schizophrenia, and hypertension, and the quarterly MDS dated 04/28/26 described the resident as cognitively intact and requiring substantial to maximum staff assistance with toilet hygiene, dependent for bathing, and independent with bed mobility and transfers. Physician orders included Risperdal 0.5 mg every morning, along with Depakote, Losartan, Potassium Chloride, Metformin, Claritin, Ativan, and a multivitamin. During observation on 05/18/26, RN #210 prepared and administered the resident’s other scheduled medications but stated Risperdal could not be given because it was not available from pharmacy. RN #210 confirmed the Risperdal had not been administered on 05/16/26, 05/17/26, or 05/18/26. The DON later confirmed the medical record lacked documentation that the medication had been administered as ordered, stated the pharmacy had not delivered it, and confirmed the physician had not been notified that the medication was unavailable. The DON also stated Risperdal was available in the facility emergency locked box for administration when not available from the pharmacy.
Infection Control Lapses During Medication Administration
Penalty
Summary
The facility failed to follow infection control procedures during medication administration for two residents. Resident #62 had diagnoses including bipolar disorder, depression with psychotic features, DM, paranoid schizophrenia, and hypertension, and was cognitively intact but required substantial to maximum staff assistance with toilet hygiene and was dependent for bathing. During medication administration, RN #210 prepared several medications for Resident #62 and placed Claritin and Losartan into her bare hands before putting them into a medication cup. The RN then administered the medications to the resident, and later confirmed she had placed those tablets into her bare hands before dispensing them. Resident #79 had diagnoses including pulmonary hypertension, DM, heart failure, and peripheral vascular disease, and was cognitively intact but required substantial to maximum staff assistance with bathing and toilet hygiene and partial to moderate assistance with bed mobility and transfers. During insulin administration, RN #210 withdrew one unit of Insulin Lispro from a vial and administered it into the resident’s left arm without performing hand hygiene or applying gloves. The RN confirmed she had not performed hand hygiene or applied gloves before giving the insulin and also confirmed she used a vial of Lispro insulin rather than the ordered kwikpen.
Unrepaired Bedside Commode and Incomplete Fall Investigation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that durable medical equipment, specifically a bedside commode, was maintained in good repair, resulting in a resident fall. The resident had multiple diagnoses including depression, COPD, CHF, severe kyphosis, osteoarthritis, osteopenia, and a history of compression fractures, and was care planned as being at risk for falls related to weakness, incontinence, psychotropic medication use, and prior falls. The resident’s MDS showed intact cognition with a BIMS score of 14, independence with eating, moderate assistance needed for bed mobility and transfers, and dependence on staff for toileting hygiene, with one fall documented in the lookback period. On the day of the incident, the resident experienced a fall while using a bedside commode. Documentation from the emergency room and the facility’s fall packet indicated that the resident had a mechanical fall when she fell through the bedside commode after the bucket fell out, leaving her stuck in the device and yelling for help. The fall packet identified equipment malfunction as a factor, describing that the bedside commode collapsed and that the commode was unstable and had been taped together prior to use. An LPN who responded to the resident’s call for help found the resident folded up in the commode, assisted her out, assessed her, and noted that the thin bar holding the bucket had been taped with surgical tape where it connected to the front of the commode frame, and that this bar gave way when the resident sat down. Staff interviews and observations further established that the commode was mechanically unsecure and had been altered with tape before the fall, and that this condition was known or observable to staff. A CNA reported seeing tape on the bedside commode and stated it was not sturdy equipment, and confirmed that no one from management had asked her for a statement or about who taped or placed the commode in the room. The LPN who completed the fall investigation packet confirmed that no management followed up with her regarding the fall or the condition of the commode. The DON acknowledged that the resident had a fall due to an issue with the bedside commode, was unaware the commode had been taped until reviewing the fall packet, and confirmed there was no investigation into which staff member taped the commode or left it in the resident’s room, nor into what should be done with mechanically unstable equipment. The facility’s fall management policy required the IDT to review all resident falls within 24–72 hours and evaluate and investigate the circumstances and probable cause, but the described follow-up did not include a thorough investigation into the commode’s condition or staff actions related to it.
Failure to Monitor Resident Weights per Facility Policy
Penalty
Summary
The facility failed to obtain and monitor a resident’s weights in accordance with its Weight Management policy, which required all residents to be weighed on admission, weekly for four weeks, and then monthly or as indicated by the physician. One resident with diagnoses including Alzheimer’s disease, an unstageable sacral pressure ulcer, metabolic encephalopathy, congestive heart failure, and essential tremor was admitted with impaired cognition, required moderate assistance with eating, and was dependent on staff for toileting hygiene, bed mobility, and transfers. Record review showed this resident was weighed on admission at 164 lbs and then on two subsequent occasions at 165.2 lbs and 164.2 lbs, with no further weights documented before the resident was hospitalized and did not return. In an interview, the unit manager confirmed the facility’s weight-monitoring expectations and verified that no additional weights were obtained or recorded for this resident beyond the three documented weights, despite the resident remaining in the facility until hospital transfer. This deficiency was cited as non-compliance with the facility’s weight management policy under Complaint Number 2709811.
Staff Failure to Use PPE in Isolation Room
Penalty
Summary
The facility failed to ensure that staff wore personal protective equipment (PPE) when entering the room of a resident on contact and droplet isolation precautions for COVID-19. Medical record review showed that a resident with end stage renal disease, dependence on renal dialysis, and atrial fibrillation was placed on isolation precautions per physician order. During observation and interview, a CNA was seen entering and cleaning the resident's room without donning PPE, despite posted signage indicating the need for PPE and facility policy requiring all staff to wear appropriate PPE when entering rooms of residents on COVID-19 isolation. The CNA stated she was unsure if PPE was required for housekeeping duties. Facility policy review confirmed that all staff, regardless of their role, are required to use PPE in such situations.
Improper Administration of Extended-Release and Delayed-Release Medications
Penalty
Summary
The facility failed to ensure proper administration of delayed-release and extended-release medications for a resident with chronic diastolic congestive heart failure, type II diabetes mellitus, and aphasia following cerebral infarction. A registered nurse was observed crushing Potassium Chloride Extended Release (ER) and Omeprazole Delayed Release (DR) tablets, mixing them with pudding, and administering them to the resident. The nurse confirmed during interview that both medications were crushed prior to administration. Review of FDA guidance and the facility's own policies revealed that both Potassium Chloride ER and Omeprazole DR are not to be crushed, as this can affect the efficacy and safety of the medications. The facility's policy required staff to check a 'Do Not Crush' list and consult with a pharmacist or physician if a medication could not be crushed. Both medications administered in this manner were listed on the facility's 'Medications Not To Be Crushed' list, indicating a failure to follow established protocols and safe medication administration practices.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to assess a resident for self-administration of medications prior to allowing the resident to keep medication at their bedside. A resident with a history of nontraumatic intracranial hemorrhage, COPD, and anxiety disorder was admitted and had a BIMS score indicating intact cognition, but required moderate assistance with all activities of daily living. The resident's care plan did not indicate the ability to self-administer medication, and there was no physician order or documented assessment for self-administration in the medical record. Despite this, repeated observations over several days showed the resident kept an albuterol inhaler at their bedside. Interviews revealed that staff were aware of the inhaler at the bedside but had not questioned the resident about it or followed the facility's process for self-administration of medications. The RN was unsure of the process and only removed the medication after being made aware of the issue. The DON confirmed that the facility policy required an assessment and physician order for self-administration, neither of which had been completed for this resident. The facility policy also required self-administration to be reflected in the care plan, which was not done.
Failure to Accurately Individualize Smoking Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans that accurately reflected the smoking status and required level of care for three residents. For each of these residents, there were discrepancies between their assessed ability to smoke safely and the interventions documented in their care plans. Specifically, care plans indicated that residents required supervision while smoking, despite smoking evaluations and staff interviews confirming that some residents were safe, independent smokers who did not require supervision, while another was assessed as an unsafe smoker who should not have been allowed to smoke independently. Resident records showed that assessments, such as the Minimum Data Set (MDS) and smoking evaluations, were completed and indicated the residents' cognitive status and smoking safety. However, the care plans were not updated to reflect these assessments. Staff interviews revealed that the care plans were often not individualized, with some staff relying on self-populated templates without editing goals and interventions to match the residents' current needs. This led to care plans that did not accurately represent the residents' smoking status or the facility's actual practices regarding supervision and safety measures. Facility policy required that care plans be specific, individualized, and based on interdisciplinary assessments, including the degree of supervision necessary for residents who smoke. Despite this, the care plans for the three residents did not align with their most recent smoking evaluations or the facility's smoking policy. Interviews with nursing staff, the DON, and the administrator confirmed that the care plans were inaccurate and not up to date, and that staff did not always understand the need to personalize care plans beyond the default information provided by the electronic system.
Failure to Update Care Plan Following Diet Change
Penalty
Summary
The facility failed to update a resident's care plan to accurately reflect a change in diet from nothing by mouth (NPO) to a pureed diet. The resident, who had a history of protein-calorie malnutrition and dysphagia, was initially admitted with orders for NPO status and tube feeding. Despite subsequent changes in the resident's dietary orders, including the introduction of a pureed diet and honey thickened liquids, the care plan continued to include outdated interventions and need statements referencing NPO status and tube feeding. Observations confirmed that the resident was receiving a pureed diet, yet the care plan was not consistently updated to reflect this change. Interviews with facility staff, including the MDS nurse, DON, and Administrator, revealed that care plans were expected to be updated in real time and during regular reviews, but this did not occur for the resident in question. The facility's policy required care plans to be individualized and updated with significant changes, but the care plan for this resident retained obsolete information and did not accurately communicate the current dietary needs to staff. This failure was identified through record review, staff interviews, and direct observation of the resident receiving oral nutrition.
Failure to Provide Required Nail Care for Dependent Resident
Penalty
Summary
The facility failed to provide appropriate nail care for a resident who required assistance with activities of daily living (ADLs) due to hemiplegia and hemiparesis following a cerebrovascular event, as well as other medical conditions including type 2 diabetes mellitus and chronic kidney disease. Facility policy required daily personal hygiene, including nail care, and specified that nails should be kept neatly trimmed. The resident's care plan also directed staff to keep fingernails trimmed and clean. Despite these requirements, observations on multiple occasions revealed that the resident's fingernails on the hemiparetic hand were long and extended past the fingertips. The resident reported wanting their nails trimmed and stated that only a nurse could perform this task due to their diabetes diagnosis. Interviews with staff confirmed that certified nurse aides were responsible for cleaning nails during ADL care, but only nurses were permitted to trim nails for diabetic residents. Both the RN and DON acknowledged that the resident's fingernails should have been trimmed and should not extend past the fingertips, in accordance with facility policy and expectations. The administrator also confirmed that nails should be kept clean and trimmed to the resident's preference. Despite these expectations and policies, the resident did not receive the required nail care, resulting in a deficiency.
Failure to Prevent Resident Access to Unsecured Medications
Penalty
Summary
The facility failed to ensure a resident's environment was free from accident hazards by allowing a resident to keep multiple medications, including prescription and over-the-counter items, at their bedside without an assessment for self-administration or a physician's order permitting self-administration. The resident, who had a history of acute and chronic respiratory failure, pneumonia, and COPD, was observed with fluticasone nasal spray, saline nasal spray, triple antibiotic ointment, and eye drops on their bedside table. The resident reported having ordered and received these items independently and kept them within reach for personal use, without staff knowledge or documentation in the care plan regarding self-administration. Staff interviews confirmed that facility policy prohibits residents from keeping medications in their rooms unless specifically authorized by a physician and following a self-administration assessment. Multiple staff members, including a CNA, LPN, RN, and the DON, verified that medications should not be left at the bedside and that no residents in the facility were authorized to self-administer medications at the time. The presence of these medications in the resident's room was not identified or addressed by staff until observed during the survey, indicating a lapse in supervision and adherence to facility policy.
Failure to Secure Indwelling Catheter Tubing During Resident Care
Penalty
Summary
A deficiency was identified when a resident with a history of benign prostatic hyperplasia, obstructive and reflux uropathy, and urinary retention, who was dependent on staff for toileting and had an indwelling urinary catheter, was observed to have their catheter tubing unsecured during care. The resident's care plan specifically required that the catheter tubing be secured to prevent trauma and that staff observe and document for pain or discomfort related to the catheter. Despite these interventions, during catheter care, staff were observed to tug on the catheter tubing multiple times while providing care and repositioning the resident's brief, and the tubing was not anchored to the resident's thigh as required. Interviews with staff confirmed that the resident had not had a catheter anchor since returning from a recent hospital stay, and the CNA providing care acknowledged the absence of an anchor. The RN was unaware of the lack of an anchor, and the DON stated that all residents with indwelling catheters were expected to have an anchor to prevent trauma. The administrator deferred nursing issues to the DON and indicated that a physician order would be obtained if needed.
Failure to Prevent Significant Medication Error in Insulin Administration
Penalty
Summary
A deficiency occurred when a resident with type 2 diabetes mellitus and severe cognitive impairment received insulin glargine injections despite physician orders specifying that the medication should not be administered if the resident's blood sugar was below 140. Documentation showed that the resident was given insulin on two occasions when their blood sugar levels were 118 and 126, both below the ordered threshold. The resident's care plan directed staff to administer medications as ordered and to report abnormal findings to the physician. Interviews with the DON and Administrator confirmed that staff were expected to follow physician orders and seek clarification if there was any uncertainty. Facility policy also required medications to be administered in accordance with written physician orders. Despite these expectations and policies, the insulin was administered outside of the prescribed parameters, resulting in a significant medication error.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with significant risk factors, including an indwelling catheter, severe cognitive impairment, and multiple unhealed pressure ulcers. According to the resident's care plan and physician orders, EBP was required due to the presence of open wounds and a urinary catheter, as well as a history of MRSA. During an observed wound care session, two LPNs provided treatment without donning gowns, although gloves were used. Their scrub tops came into contact with the resident's bed and covers during the procedure. PPE supplies were available outside the room, but the required gowns were not utilized. Interviews with the involved LPNs and facility leadership confirmed that staff were aware of the EBP requirements and had been trained to use both gloves and gowns during high-contact care activities such as wound care. One LPN incorrectly believed that EBP was no longer necessary since the resident had completed antibiotics and was not on contact isolation, while the Infection Preventionist and Director of Nursing clarified that EBP should have been maintained due to the ongoing presence of wounds and a catheter. Facility policy explicitly required the use of gloves and gowns for residents with wounds or indwelling devices during high-contact care, but this protocol was not followed during the observed incident.
Failure to Complete and Document Smoking Assessments per Facility Policy
Penalty
Summary
The facility failed to implement its smoking policy as required, specifically by not completing smoking assessments fully or in a timely manner for three residents who used tobacco products. According to the facility's policy, residents who smoke must be evaluated upon admission, readmission, with significant change, and at regular intervals thereafter. However, documentation and interviews revealed that these assessments were either missing or incomplete at critical times, such as after readmission or during required evaluation periods. One resident with a history of acute kidney failure was admitted and later readmitted, but did not have a smoking evaluation completed upon readmission as required by policy. Another resident with chronic diastolic heart failure was also readmitted without a subsequent smoking evaluation. A third resident with polyneuropathy had a smoking evaluation on file, but the assessment was left incomplete, with the summary section blank, failing to indicate whether the resident was a safe or unsafe smoker. Interviews with facility staff, including the MDS nurse, ADON/Infection Preventionist, DON, and Administrator, confirmed that smoking assessments were not consistently completed according to the facility's policy. Some staff were unaware of the specific requirements for reassessment, and documentation in the medical records did not reflect adherence to the policy. The facility's own smoking policy clearly outlined the need for timely and complete evaluations, but these procedures were not followed for the residents reviewed.
Failure to Protect Resident from Misappropriation of Property
Penalty
Summary
A resident with moderate cognitive impairment and a diagnosis of spinal stenosis was admitted to the facility with $669 in their wallet, as documented on the Inventory of Personal Effects. Upon admission, a CNA and the resident counted the money, and the CNA handed it to a nurse, who placed it in a medication cart's narcotic drawer. The charge nurse notified a unit manager about the money, and the unit manager instructed the charge nurse to store it in the narcotic drawer. When the charge nurse returned to work, the money was missing from the drawer. Multiple staff interviews confirmed that the money was last seen when placed in the medication cart, and no one reported moving or seeing the money afterward. The resident later requested their money, but staff were unable to locate it. The facility's investigation, which included staff interviews and a review of the medication cart assignments, was unable to determine what happened to the resident's money or who took it. The incident was reported to the police, and the facility's policy required protection of residents from misappropriation of property. The money was never recovered, and the facility was found to have failed to protect the resident's right to be free from misappropriation of property.
Failure to Timely Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an allegation of misappropriation of property within 24 hours, as required by policy and regulation. A resident with moderate cognitive impairment was admitted with $669.00 in their wallet, which was placed by staff in a narcotic drawer of a medication cart upon admission. When the charge nurse returned to the facility, the money was missing, and no staff could account for its location after it was initially stored. The incident was documented, and the facility's investigation indicated that the money was in the facility's possession but was not stored or reported correctly to the Administrator or Director of Nursing (DON). Staff became aware of the missing money on one date, and the resident inquired about it several days later, but the incident was not reported to the state survey agency until nearly two weeks after the initial discovery. The facility's policy required immediate reporting of such allegations to the Administrator and DON, and notification to state or federal agencies within specified timeframes. Interviews confirmed that the DON was not aware of the allegation until much later, and the Administrator acknowledged the delay in reporting to the state survey agency.
Failure to Thoroughly Investigate Misappropriation of Resident Property
Penalty
Summary
The facility failed to thoroughly investigate an allegation of misappropriation of property involving a resident who was admitted with a diagnosis of spinal stenosis and had moderate cognitive impairment, as indicated by a BIMS score of 10. Upon admission, the resident had $669.00 in their wallet, which was placed by a charge nurse in a double-locked narcotic drawer in a medication cart, as directed by a unit manager. When the charge nurse returned several days later, the money was missing, and the unit manager denied moving it. The incident was reported to the Administrator and Director of Nursing after the resident inquired about the missing money. Facility investigation documents showed that several staff members who had access to the medication cart during the relevant period were not interviewed, and there was no evidence of statements or interview details for most of the nurses identified as having access. The facility's policy required a thorough investigation, including interviews with all staff who may have had contact with the resident or knowledge of the incident. Both the DON and Administrator acknowledged that the investigation was not thorough, as required by facility policy.
Failure to Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident to the state agency, as required by their policy. The incident involved a resident with severely impaired cognition, who required extensive assistance for daily activities and was dependent for eating. The resident was admitted with a diagnosis of acute respiratory failure and later discharged against medical advice. After the resident's discharge, a hospital evaluation revealed an allegation of sexual abuse, which was reported to the police and Ombudsman. The facility's Administrator became aware of the allegation after reviewing hospital documentation, but acknowledged that the facility did not file a self-reported incident (SRI) with the state agency. The facility's policy mandates that allegations of abuse be reported within two hours or no later than 24 hours, depending on the severity. The Administrator confirmed that the facility did not adhere to this policy, resulting in a deficiency being cited under Complaint Number OH00160670.
Failure to Investigate Allegation of Sexual Abuse
Penalty
Summary
The facility failed to investigate an allegation of sexual abuse involving a resident with severely impaired cognition, as indicated by a Brief Interview Mental Status (BIMS) score of two. The resident required extensive two-person assistance for bed mobility, transfers, and toileting, and was dependent on eating. The resident was admitted to the facility with a diagnosis of acute respiratory failure and later discharged against medical advice. A subsequent hospital evaluation revealed an allegation of sexual abuse, which was reported to the police and Ombudsman, and a Sexual Assault Nurse Examiner (SANE) evaluation was conducted. The facility's Administrator became aware of the allegation after reviewing hospital documentation but did not conduct a thorough investigation as required by the facility's Abuse Prohibition Policy. The policy mandates that investigations be completed within five days and include interviews with the person reporting the incident, the resident if possible, any witnesses, staff in contact with the resident, and a review of all circumstances surrounding the incident. However, the Administrator only questioned male staff verbally and did not obtain written statements or any other investigative documentation, confirming that no evidence of a completed investigation was available.
Medication Transcription and Administration Errors
Penalty
Summary
The facility failed to ensure that a resident's medications were accurately transcribed upon admission, resulting in multiple medication omissions and errors. Specifically, Resident #217, who was admitted with diagnoses including surgical aftercare, spinal stenosis, reduced mobility, and muscle weakness, did not receive Atenolol and Lidocaine Patch EX from 03/25/24 through 03/28/24. Additionally, there was a transcription error for Buprenorphine HCl-Naloxone HCl, which was incorrectly ordered and documented as given when it was not available. Alendronate Sodium was also administered on the wrong day due to an incorrect transcription in the electronic medication record (EMR). These errors were confirmed through medical record reviews and staff interviews, including admissions from LPN #222 and LPN/Unit Manager #187 that the medications were not given as ordered or were incorrectly transcribed. The nurse practitioner's progress note on 03/26/24 indicated that Resident #217 was clinically stable but had not received Suboxone since admission, despite a history of drug use. The physician's orders from 03/24/24 were not accurately transcribed, leading to the administration of Alendronate on Monday instead of Friday, and the omission of Atenolol and Lidocaine Patch EX until 03/29/24. The Buprenorphine HCl-Naloxone HCl was incorrectly transcribed and documented as given on 03/26/24, although it was not available from the pharmacy. Interviews with LPN #222 and LPN/Unit Manager #187 confirmed these discrepancies and the lack of proper medication administration. Further interviews revealed that the facility had reached out to a local Suboxone Clinic prior to Resident #217's admission, but there was no follow-up, and the clinic personnel did not visit the resident. The Regional Clinical Coordinator confirmed that the facility's protocol involves contacting the Suboxone clinic to ensure continuity of care for residents on Suboxone. This deficiency was investigated under Complaint Number OH00152864 and represents non-compliance with the requirement to provide pharmaceutical services to meet the needs of each resident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 528 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near West Carrollton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sycamorespring Of Miamisburg | 0.7 mi | ★★★★★ | 3 | 0 |
| Wood Glen Alzheimer's Community | 0.8 mi | ★★★★★ | 16 | 0 |
| Vienna Springs Health Campus | 1.1 mi | ★★★★★ | 1 | 0 |
| Sycamore Trails Post Acute | 1.2 mi | ★★★★★ | 0 | 0 |
| Walnut Creek Nursing Center | 2.5 mi | ★★★★★ | 13 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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