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 Mount Washington Care Center during CMS and state inspections, most recent first.
Surveyors found that call lights were not answered in a timely manner, leading to delayed care for several residents, including individuals with chronic kidney disease, progressive multiple sclerosis, emphysema, neuromuscular bladder dysfunction, prior intracerebral hemorrhage, diabetes, atrial fibrillation, hypertension, and total incontinence. One resident’s call light remained unanswered for 27 minutes after activation, while other residents and a family member reported routinely waiting an hour or more. A staff member confirmed receiving complaints and personally observing call lights unanswered for 25–35 minutes. A CNA stated call lights should ideally be answered within minutes, while the DON acknowledged there were no call light audits and no knowledge of average response times, and a corporate RN confirmed there was no formal standard, only an ideal response time under 20 minutes.
A resident with a tracheostomy and acute respiratory needs was admitted without physician orders for tracheostomy care or oxygen administration. Staff relied on nursing judgment for respiratory interventions, and documentation lacked required orders, resulting in the resident experiencing respiratory distress and requiring emergency transfer. Facility policy requiring physician-directed tracheostomy care was not followed.
A resident with a history of falls and cognitive impairment experienced an unwitnessed fall, resulting in a femoral neck fracture. Despite reporting significant pain, the resident received inadequate pain management, with only one undocumented dose of Tylenol given. The resident's pain persisted, and no further interventions were provided until the resident was sent to the hospital 19 hours later, where a fracture was confirmed, necessitating surgery.
The facility failed to conduct quarterly care conferences for several residents, as required by its policy. This deficiency was identified through medical record reviews and staff interviews, revealing that residents did not receive the mandated care conferences in certain quarters of 2024. The Social Services Director confirmed these findings, indicating a lapse in ensuring residents and their representatives were informed and involved in care planning.
The facility failed to use the correct transfer sling for a mechanical lift, affecting a resident with multiple medical conditions. Staff used a Proactive sling with a Handicare lift, contrary to manufacturer instructions, and no Handicare slings were available. Additionally, two residents who smoked were not properly assessed for safe smoking practices, with one never evaluated and the other not reassessed for over a year. Staff interviews confirmed these deficiencies, and the facility's policies were not followed.
The facility's kitchen was found unsanitary, affecting 78 residents. Observations included debris on vents, unlabeled food, and expired items. Staff failed to change gloves between tasks and lacked proper hair and beard coverings. The Registered Dietitian confirmed these issues, which violated facility policies on food safety and hygiene.
Two residents in an LTC facility did not receive timely meal service. One resident, with severe cognitive impairment and requiring meal assistance, waited over 20 minutes for help, while another resident's meal was misrouted, causing a similar delay. Staff interviews confirmed these issues, highlighting a failure to serve meals simultaneously to all residents.
The facility failed to notify the Ombudsman when two residents were transferred to the hospital. One resident with moderate cognitive impairment was admitted to the hospital multiple times without notification, and another resident with multiple health issues was discharged without informing the Ombudsman. The Social Services Director confirmed the lack of notifications since April 2024, despite facility policy requiring such notifications.
A resident at risk for skin breakdown did not receive the necessary interventions as ordered by a physician. Despite orders for heel lift boots and positioning pillows, observations revealed these measures were not in place. Staff interviews confirmed the absence of these preventive measures, highlighting a deficiency in care.
A facility failed to provide adequate hydration for a dependent resident, leading to hospital admission for dehydration-related conditions. Additionally, the facility did not properly monitor or address significant weight changes in two residents, failing to notify physicians or implement effective interventions. Observations showed a resident's water pitcher was consistently out of reach, and significant weight fluctuations were not communicated or managed appropriately.
The facility failed to properly label and store insulin vials, affecting four residents. Observations showed that insulin vials were either not dated when opened or exceeded the 28-day expiration period. Interviews confirmed that insulin should be dated and discarded after 28 days, as per facility policy and pharmacy guidelines.
A resident with multiple health conditions did not receive timely dental care services, despite having a physician order and requesting a dental appointment for denture repair. Observations showed the resident had no dentures, affecting their ability to enjoy food. Staff interviews confirmed no dental appointments were made since admission.
A resident with a history of ESBL, a multi-drug resistant organism, did not receive appropriate infection control measures during incontinence care. A CNA failed to perform hand hygiene before applying gloves and used clean linens placed on an unclean bedside table. The resident was not placed on enhanced barrier precautions (EBPs) despite having ESBL, and there were no active orders or signage indicating the need for EBPs. The facility's policies on hand hygiene and EBPs were not followed.
Failure to Respond Timely to Resident Call Lights
Penalty
Summary
Surveyors identified a deficiency related to untimely response to resident call lights, resulting in delays in care for multiple residents. One resident with chronic kidney disease (stage four), esophageal obstruction, and hypertensive heart disease, who was cognitively intact and had no behavioral issues, activated his call light because he was cold. Observation showed the call light was activated at 11:12 A.M. and not answered until 11:39 A.M., a 27‑minute delay. A CNA stated that call lights should ideally be answered within seven to eight minutes. Another cognitively intact resident with progressive multiple sclerosis, emphysema, neuromuscular bladder dysfunction, and an above‑knee amputation reported having to wait longer than an hour on multiple occasions for call lights to be answered, causing delays in care. A third resident with moderately impaired cognition, nontraumatic intracerebral hemorrhage, type II diabetes mellitus, atrial fibrillation, hypertension, and total bowel and bladder incontinence, along with his wife, reported sometimes waiting an hour or more for call light response; prior care conference documentation showed the family had voiced concerns about nurses not responding, leading the resident to call out for help. A staff member reported receiving complaints from residents about long call light response times and personally observing call lights unanswered for 25 to 35 minutes. The DON stated the facility does not perform call light audits or know the average response time, and the President of Clinical Services RN reported the facility has no standard for call light response times, only an ideal of under 20 minutes.
Failure to Implement Physician Orders for Respiratory Care
Penalty
Summary
The facility failed to implement physician orders for appropriate respiratory care for a resident with significant respiratory needs. Upon admission, the resident had diagnoses including acute respiratory failure, tracheostomy, pneumonia, intracerebral hemorrhage, and functional quadriplegia, and was dependent for all care. Medical record review showed there were no physician orders for tracheostomy care or oxygen administration documented in the resident's baseline care plan, progress notes, admitting physician's orders, or the Treatment Administration Record. Staff interviews confirmed that the resident was admitted from a subacute care hospital with a tracheostomy in place and was receiving oxygen, but no orders for tracheostomy care or oxygen administration were obtained or implemented upon admission. Facility staff, including an LPN, relied on nursing judgment to determine the administration and flow rate of oxygen for the resident, rather than following physician orders. When the resident experienced respiratory distress and had a low oxygen saturation, the LPN increased the oxygen flow rate based on a physician's phone instruction and called emergency services. The facility's policy required tracheostomy care to be provided according to physician orders and professional standards, but this was not followed in the resident's case.
Failure to Manage Resident's Pain After Fall
Penalty
Summary
The facility failed to effectively manage the pain of a resident following an unwitnessed fall, which resulted in a left subcapital femoral neck fracture. The incident occurred when the resident fell in her room and reported left leg and knee pain to two LPNs. Despite receiving one dose of PRN Tylenol, there was no documentation on the medication administration record (MAR), and the resident continued to exhibit signs of pain, such as yelling out and facial grimacing. The on-call Nurse Practitioner ordered an x-ray and an ice pack for pain, but no additional pain medications or interventions were provided until the resident was sent to the hospital approximately 19 hours later. The resident, who had a history of major depressive disorder, generalized anxiety disorder, and atrial fibrillation, was at risk for falls and had a recent pain assessment indicating no pain in the last five days. After the fall, the resident expressed pain at a level of six out of ten and showed nonverbal signs of pain. The fall investigation revealed that the resident attempted to transfer and ambulate herself, leading to the fall due to weakness and poor safety awareness. Despite these findings, there was no documentation of pain levels on the MAR, and the resident's pain was not adequately addressed. Interviews with staff and review of facility policies highlighted the lack of appropriate pain management. The Director of Nursing confirmed that the resident showed multiple signs of pain after the fall, but there was no documentation of pain medications being administered before the resident was sent to the hospital. The facility's pain management policy emphasized the need for timely assessment and intervention for acute pain, which was not followed in this case, leading to the resident's prolonged discomfort and eventual need for surgical intervention.
Failure to Conduct Quarterly Care Conferences
Penalty
Summary
The facility failed to ensure that care conferences were held as required for residents and their representatives, affecting seven residents. The deficiency was identified through medical record reviews, resident and staff interviews, and policy reviews. The facility's policy mandates that care conferences be held quarterly to discuss the plan of care with residents and/or their representatives. However, the review revealed that several residents did not have documented care conferences in the required quarters of 2024. For instance, Resident #02 only had care conferences documented in May and December, missing the first and third quarters. Similarly, Resident #10 had care conferences in June and November, missing the first and third quarters as well. Other residents, such as Resident #17, #35, #36, #42, and #56, also did not receive care conferences quarterly as required. Interviews with the Social Services Director confirmed these findings, verifying that the residents did not receive the mandated quarterly care conferences. The facility's failure to adhere to its policy on care planning and resident participation resulted in a deficiency, as residents and their representatives were not adequately informed or involved in their care planning at the required intervals.
Improper Sling Use and Smoking Evaluation Lapses
Penalty
Summary
The facility failed to utilize the correct transfer lifting sling for a mechanical lift, as specified in the manufacturer's directions. This deficiency was observed during the transfer of a resident with multiple medical conditions, including multiple sclerosis and an above-knee amputation, who was dependent on staff for transfers via mechanical lift. Certified Nursing Assistants (CNAs) used a Proactive mechanical lift transfer sling with a Handicare mechanical lift, despite the manufacturer's instructions indicating that only Handicare slings should be used. The facility did not have any Handicare slings available, and staff were unaware of the specific requirements for sling use with the mechanical lifts. Additionally, the facility failed to properly assess and evaluate residents for safe smoking practices. Two residents identified as smokers did not have up-to-date Safe Smoking Evaluations. One resident, with diagnoses including multiple sclerosis and nicotine dependence, had no documented evidence of a Safe Smoking Evaluation ever being completed. Another resident, with conditions such as lumbar disc degeneration and dementia, had not been reassessed for safe smoking since the previous year. The facility's policy required quarterly evaluations for residents who smoke, but this was not adhered to. Interviews with staff, including CNAs and the Director of Nursing (DON), confirmed the lack of appropriate equipment and assessments. The DON acknowledged that the Proactive slings were not universal and should not be used with Handicare lifts, and also verified the oversight in conducting Safe Smoking Evaluations. The facility's policies on mechanical lift use and smoking evaluations were not followed, leading to these deficiencies.
Sanitation and Food Handling Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a sanitary kitchen environment, which affected 78 residents who received food from the kitchen. Observations revealed several issues, including a gray material blowing from a wall fan towards a food preparation table, open and unlabeled food bags in the dry storage area, and a buildup of gray debris on exhaust vents above the stove. Additionally, there were large unopened food cans without delivery dates and an expired cottage cheese container in the walk-in refrigerator. The Registered Dietitian confirmed the lack of proper labeling and the need for cleaning the fans and vents. Further observations highlighted improper food handling practices by staff. A staff member was seen using the same gloves to handle food and non-food items without changing gloves or performing hand hygiene. Another staff member and a diet aid were observed without proper beard coverings, and hair was not fully covered by hairnets. The same staff member also failed to change gloves between handling dirty and clean dishwashing tasks. The facility's policies on food safety, storage, personal hygiene, and dishwashing were not adhered to, as confirmed by interviews with staff and the Registered Dietitian.
Failure to Serve Meals Timely to Residents
Penalty
Summary
The facility failed to serve meals to all residents in the dining room in a timely manner, affecting two residents who were dependent on staff assistance. Resident #65, who has diagnoses including dementia, cerebral infarction, hemiplegia, dysphagia, anxiety disorder, restlessness, and agitation, was observed in a tilting wheelchair in the dining room. Despite her meal being placed in front of her at 12:33 P.M., she was not assisted by a CNA until 12:54 P.M., during which time she appeared anxious. Resident #71, with diagnoses of hemiplegia, dysphagia, restlessness, and agitation, was also affected. He was seated with other residents who were served their meals at 12:33 P.M., but he did not receive his meal tray until 12:51 P.M. Interviews with staff revealed that Resident #71's meal tray had been misrouted to the wrong unit daily for nearly two weeks, causing him to wait nearly 20 minutes for his meal while others ate. CNA #178 confirmed the misrouting issue and stated that all residents should be served meals simultaneously. The Registered Dietitian verified that both residents should have received their meals and assistance at the same time as the other residents. CNA #195 acknowledged that Resident #65's meal was left in front of her for over 20 minutes and noted that there were two CNAs available to assist the three residents requiring meal assistance.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the Ombudsman when residents were transferred or discharged to the hospital, affecting two residents. Resident #42, who had moderate cognitive impairment and required assistance with daily activities, was admitted to the hospital on three occasions without the Ombudsman being notified. The Social Services Director confirmed that there had been no notifications to the Ombudsman regarding hospitalizations or discharges since April 2024. Similarly, Resident #58, who had multiple diagnoses including cerebral infarction with hemiplegia and COPD, was discharged to the hospital without the Ombudsman being informed. The facility's policy required that a copy of the transfer or discharge notice be sent to the Ombudsman at the same time as it was provided to the resident and their representative. However, this procedure was not followed, as verified by the Social Services Director.
Failure to Implement Skin Breakdown Prevention Measures
Penalty
Summary
The facility failed to implement necessary interventions to prevent skin breakdown for a resident at risk. Resident #23, who was admitted with diagnoses including hemiplegia, aphasia, dementia, dysphagia, and malnutrition, was ordered by a physician to wear heel lift boots while in bed to prevent skin breakdown. Additionally, therapy notes indicated the need for a positioning pillow under the resident's right knee. Despite these orders, observations on multiple occasions revealed that the resident did not have the required heel lift boots or positioning pillows in place. Interviews with staff, including LPNs and the Director of Nursing, confirmed the absence of these preventive measures. The staff acknowledged that the resident should have had the heel lift boots and positioning pillows as per the physician's orders to prevent skin breakdown. The facility's failure to adhere to these orders and implement the necessary interventions for Resident #23 was identified as a deficiency during the survey.
Inadequate Hydration and Nutrition Monitoring
Penalty
Summary
The facility failed to provide adequate hydration for a dependent resident, Resident #17, who was unable to complete a Brief Interview for Mental Status due to being rarely or never understood. Resident #17 was dependent on staff for eating, toileting, bathing, dressing, and transfers. Observations over several days revealed that Resident #17's water pitcher was consistently placed out of reach, and fluids were not offered during interactions with staff. This lack of access to hydration likely contributed to Resident #17's hospital admission for a urinary tract infection, acute encephalopathy, and acute kidney injury on chronic kidney disease stage three, attributed to poor oral intake. The facility also failed to adequately monitor and address significant weight changes in Resident #10. Despite being at moderate to severe nutritional risk, Resident #10 experienced an unplanned weight gain of 36.81 percent over a period of less than a year. The facility did not notify the physician of the resident's significant weight gain or implement effective interventions. The Registered Dietitian (RD) noted the weight gain but attributed it to the weight of the resident's wheelchair, and the Director of Nursing (DON) could not provide insight into the weight gain or the facility's response. Additionally, Resident #73 experienced a significant weight loss of 20.63 percent over 60 days, yet there was no documentation of dietary progress notes or assessments between December and February. The facility's policy required monitoring and documentation of weight and dietary intake, as well as reporting significant weight changes to the physician, but these actions were not taken. The DON confirmed that Resident #73 was not discussed in a risk meeting, indicating a lack of oversight and communication regarding the resident's nutritional status.
Improper Labeling and Storage of Insulin Vials
Penalty
Summary
The facility failed to ensure that insulin vials were properly labeled and stored, affecting four residents. Observations revealed that insulin vials for these residents were either not dated when opened or had exceeded the 28-day expiration period after being opened or removed from refrigeration. Specifically, Resident #09's Novolog insulin was opened on 01/22/25, Resident #30's Lantus and Humalog insulins were opened on 01/03/25 and 11/13/24 respectively, Resident #41's Lantus insulin was not dated, and Novolog insulin was opened on 11/13/24, and Resident #49's Humalog insulin was opened on 01/14/25. Interviews with staff and the consulting pharmacist confirmed that insulin vials should be dated when opened and discarded after 28 days. The facility's policy and guidelines from the pharmacy provider also stipulated that insulin products must be labeled with the date opened and discarded before expiration. The failure to adhere to these guidelines resulted in the improper labeling and storage of insulin vials, which were not returned to the pharmacy for proper labeling or disposal as required by the facility's policy.
Failure to Provide Timely Dental Care Services
Penalty
Summary
The facility failed to provide timely dental care services for a resident, identified as Resident #58, who was admitted on 09/01/23 and discharged to the hospital on 08/19/24. The resident had multiple diagnoses, including hemiplegia, cerebral infarction, dysphagia, chronic obstructive pulmonary disease, diabetes, and malnutrition. A physician order dated 09/01/23 indicated that the resident could see dental services as needed. However, there was no documented evidence of any dental appointment being made for the resident since admission. During a care conference on 12/04/24, the resident requested a dental appointment to have dentures repaired, but no action was taken to fulfill this request. Observations on 02/24/25 revealed that the resident had no natural teeth and no dentures in place, which affected their ability to enjoy food. Interviews with the resident and staff confirmed that the resident had not seen a dentist since admission, and there were no dental appointments set up. The Social Services Designee acknowledged the delay in dental services due to appointment complications and confirmed that the necessary paperwork for dental services had been completed, but no services had been provided since the resident's admission.
Inadequate Infection Control During Incontinence Care
Penalty
Summary
The facility failed to implement appropriate infection control measures during incontinence care for a resident diagnosed with Alzheimer's disease, type two diabetes mellitus, paranoid schizophrenia, and major depressive disorder. The resident, who was dependent on staff for activities of daily living, had a history of frequent urinary tract infections with extended spectrum beta-lactamase (ESBL), a multi-drug resistant organism (MDRO). During an observation, a Certified Nursing Assistant (CNA) did not perform hand hygiene before applying gloves and placed clean linens on an unclean bedside table before using them for incontinence care. The CNA only wore gloves during the procedure and was unaware of the need for additional personal protective equipment (PPE) as part of enhanced barrier precautions (EBPs). The Director of Nursing and a Registered Nurse confirmed that the resident should have been on EBPs due to the presence of ESBL, but there were no active orders or signage indicating this requirement. The facility's hand hygiene policy required staff to perform hand hygiene before donning gloves, and the CDC guidelines indicated that EBPs involve gown and glove use during high-contact care activities for residents with MDROs. The facility's policy on EBPs was not dated, but it stated that EBPs should be implemented to prevent the transmission of MDROs, which was not followed in this case.
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Illustrative
What surveyors actually found near you
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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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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Cincinnati
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Residence At Salem Woods | 1.2 mi | ★★★★★ | 0 | 0 |
| Anderson, The | 2.2 mi | ★★★★★ | 2 | 0 |
| Carmel Manor | 3.9 mi | ★★★★★ | 15 | 0 |
| Forest Hills Healthcare Center. | 4 mi | ★★★★★ | 16 | 0 |
| Siena Gardens Rehabilitation & Transitional Care | 4.7 mi | ★★★★★ | 2 | 0 |
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