Above 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 Ohio Living Quaker Heights during CMS and state inspections, most recent first.
A resident with multiple comorbidities, impaired cognition, and a history of fractures reported arm pain and stated she had been in a fight with a CNA after receiving care. The CNA informed an agency nurse, who assessed the resident and noted no findings, but the CNA did not report the allegation to the DON or other supervisory staff as required by the facility’s abuse policy. The next day, an RN was informed the resident was complaining of left arm pain and had reported a fight with a CNA; on assessment, the RN found bruising and swelling, notified the DON and physician, and the resident was sent to the ED, where a left forearm fracture was diagnosed. The DON confirmed that the CNA failed to follow the abuse reporting policy requiring immediate reporting of all abuse allegations.
A resident with multiple comorbidities, moderately impaired cognition, and a history of fractures complained of arm pain and stated she had been in a fight with a CNA after receiving care. The CNA informed an agency nurse, who assessed the resident and found no issues, but the CNA did not report the allegation to the DON or other supervisory staff as required. The next day, an RN noted bruising and swelling of the resident’s arm, arranged transfer to the ED, and a fracture was diagnosed. Surveyors determined the facility failed to report the abuse allegation immediately in accordance with its abuse reporting policy.
Surveyors found that two residents who were cognitively impaired, incontinent, and dependent on staff for ADLs did not have accessible call lights, despite a facility policy requiring call devices to be easily accessible at all times. One resident’s call light was placed on a nightstand out of reach, and another’s was wrapped tightly around a lower bed rail, preventing use. A nurse educator and an LPN each confirmed that the call lights were not within reach of the residents.
Surveyors identified that staff failed to follow infection prevention and control policies for two residents. One resident with multiple complex conditions, including use of a urinary catheter and G-tube, had a care plan requiring Enhanced Barrier Precautions, and signage directing staff to wear gloves and gowns for device care; however, nurses routinely provided tube feeds, flushes, and medications in a common area without any PPE. In a separate incident, a CNA provided incontinence care to another resident, did not change gloves afterward, then picked up the resident’s call light from the floor with the same gloved hand and handed it to the resident, who placed it in her mouth, without performing hand hygiene or cleaning the call light.
A resident with multiple chronic conditions did not receive several prescribed medications due to unavailability, and the physician was not notified as required by facility policy. The MAR showed discrepancies between documented administration and actual medication availability. The DON confirmed the lack of physician notification, and staff interviews revealed confusion about when to notify physicians regarding missed medications. The resident later experienced an acute change in condition and was transferred to the hospital.
A resident with multiple chronic conditions who was dependent on staff for bathing did not receive scheduled showers as required by facility policy. Documentation and staff interviews confirmed that the resident only received two showers in one month and none the following month, despite the policy of two scheduled showers per week.
A resident with multiple chronic conditions did not consistently receive prescribed medications due to unavailability and documentation discrepancies. MARs showed missed doses and blank entries, while pharmacy records confirmed gaps in medication supply. The DON and PCP confirmed that medications were not always on hand and that the physician was not notified of these issues, resulting in significant medication errors.
Failure to Follow Abuse Reporting Policy After Resident Allegation of Injury
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow its abuse policy when a resident reported possible abuse associated with care. The resident, who had multiple medical conditions including a displaced fracture of the upper left humerus, pain related to an orthopedic prosthesis, unsteadiness, muscle weakness, osteoporosis, hypertensive heart disease, peripheral vascular disease, nutritional anemia, moderately impaired cognition (BIMS score of 7/15), and frequent incontinence, complained of a broken arm and pain after care provided by a CNA. The CNA reported this complaint only to an agency nurse, who performed an assessment on the same day and documented no findings. The CNA did not report the allegation to the DON or any other appropriate facility staff member as required by the abuse policy, which states that all allegations of abuse, neglect, and misappropriation must be reported immediately to designated supervisory personnel. On the following day, during evening shift change, an RN was notified that the resident was complaining of left arm pain and reported having been in a fight with a CNA. The RN immediately assessed the resident and observed bruising and swelling of the left arm, notified the DON and the physician, and the resident was sent to the ED, where a left forearm fracture was diagnosed and nonsurgical management with a sling was recommended. The DON confirmed that the CNA failed to follow the facility’s Abuse, Neglect, Misappropriation and Crime Reporting policy by not immediately reporting the resident’s allegation to appropriate supervisory staff, resulting in a delay in the facility’s recognition and response to the reported incident.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse as required by its abuse, neglect, misappropriation, and crime reporting policy. A resident with multiple medical conditions, including a displaced fracture of the upper end of the left humerus, pain due to internal orthopedic prosthetic devices, unsteadiness on feet, muscle weakness, age-related osteoporosis, hypertensive heart disease, peripheral vascular disease, and nutritional anemia, was admitted on a specified date and had moderately impaired cognition with a BIMS score of 7/15. The resident was frequently incontinent and, on one occasion, complained of a broken arm and pain after care provided by a former CNA. The CNA reported the complaint to an agency nurse, who assessed the resident on that date and documented no findings, but the CNA did not report the allegation to the DON or any other appropriate staff member as required by policy. On the following day at evening shift change, an RN was notified that the resident was complaining of left arm pain and reported having been in a fight with a CNA. The RN immediately assessed the resident and found bruising and swelling to the left arm, notified the DON and physician, and the resident was sent to the ED, where a left forearm fracture was diagnosed and nonsurgical management with a sling was recommended. The facility’s policy, dated 08/14/1999, states that all allegations of abuse, neglect, and misappropriation will be reported immediately and that all staff are trained to report abuse allegations as soon as they have knowledge to designated supervisory staff. Interview with the DON confirmed that the CNA failed to report the resident’s complaint to facility staff, resulting in the allegation of abuse not being reported in a timely manner. This failure affected one resident out of nine reviewed for abuse during the survey.
Failure to Keep Call Lights Within Reach for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain residents’ call lights within reach as required by care plans and facility policy. For one resident with hemiplegia, aphasia, muscle weakness, chronic respiratory failure with hypoxia, COPD, and Type II diabetes, the MDS showed mildly impaired cognition, total dependence for all ADLs, and complete bowel and bladder incontinence. The resident’s care plan documented an ADL self-care deficit and included an intervention to keep the call light in reach at all times. During observation, the resident’s call light was found placed on a nightstand to the side of the bed, out of the resident’s reach. The nurse educator confirmed that the resident was dependent for all care and that the call light was out of reach. A second resident, with diagnoses including Type II diabetes, vascular dementia, essential hypertension, hyperlipidemia, chronic kidney disease, and celiac disease, had an MDS indicating severely impaired cognition (BIMS score of 3/15), frequent bowel and bladder incontinence, and a need for one-person physical assistance with bed mobility, transfers, dressing, toileting, personal hygiene, eating, and locomotion. Observation showed this resident’s call light wrapped tightly around a lower side bar of the bed, making it inaccessible to the resident. An LPN confirmed that the call light was not accessible. The facility’s “Responding to Call Lights” policy stated that the signal cord or device must be easily accessible to the resident at all times, which was not followed in these instances. This deficiency was investigated under a complaint number and affected two residents in a facility with a census of 58.
Failure to Follow Enhanced Barrier Precautions and Basic Infection Control Practices
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control policies, including Enhanced Barrier Precautions (EBP) and basic hand hygiene and glove use practices. Resident #5, admitted with multiple complex diagnoses including Lennox-Gastaut syndrome with status epilepticus, non-ST elevation myocardial infarction, acute respiratory failure with hypoxia, dysphagia, and acute kidney failure, had a urinary catheter, was frequently incontinent of bowel, was dependent for all ADLs, and received nutrition via G-tube. The resident’s care plan dated 03/11/2026 specified that Enhanced Barrier Precautions would be maintained per facility policy. EBP signage on the resident’s door directed staff to wear gloves and a gown for high-contact resident care activities, including device care or use for feeding tubes. However, on two observed occasions, Resident #5 was receiving tube feeds and flushes in a common area while the nurse providing this care did not wear any PPE. The DON confirmed that tube feeds, flushes, and medication administration through the G-tube routinely occurred in the common area and that nurses did not wear PPE during this care. The deficiency also includes improper glove use and hand hygiene during incontinence care for Resident #8, who had vascular dementia, anxiety disorder, major depressive disorder, weakness, and was always incontinent of bowel and bladder. During observed incontinence care, CNA #103 did not change gloves after completing care and, while still wearing the same gloves, picked up the resident’s call light from the floor and handed it to the resident, who then put the call light in her mouth. The CNA later confirmed she had not removed or changed her gloves or performed hand hygiene before handing the call light to the resident and also confirmed that the call light, which had been on the floor, was not cleaned before being given to the resident. The DON confirmed that hand hygiene should have been performed and the call light should have been cleaned prior to providing it to the resident.
Failure to Notify Physician of Missed Medication Administration
Penalty
Summary
The facility failed to notify the physician when a resident was not administered medications as ordered. Medical record review, observation, staff and physician interviews, and review of pharmacy delivery sheets and facility policy revealed that a resident with multiple diagnoses, including dementia, atrial fibrillation, and diabetes, did not receive several prescribed medications on multiple occasions. The medication administration records (MAR) showed blank entries and notations of medications being unavailable, yet there was no documentation that the physician was informed of these missed doses. Further review indicated discrepancies between the medications documented as administered on the MAR and the actual availability of those medications in the facility. The Director of Nursing (DON) confirmed that the MAR reflected administration of medications even when the facility did not have them in stock, and could not explain these discrepancies. Additionally, the DON verified that there was no evidence of physician notification regarding the missed medications, despite facility policy requiring immediate notification for changes in treatment. Interviews with staff revealed a lack of understanding regarding the need to notify the physician about missed medications, with one LPN stating she would only notify the physician if the medication was considered important, but could not define what constituted an important medication. The resident in question experienced an acute change in condition, including altered mental status and abnormal vital signs, and was subsequently transferred to the hospital. The primary care physician confirmed he was not notified of the medication discrepancies.
Failure to Provide Scheduled Showers to Dependent Resident
Penalty
Summary
Facility staff failed to provide scheduled showers to a resident who was dependent on staff for personal hygiene and bathing. Medical record review showed that the resident, who had multiple diagnoses including anxiety disorder, major depressive disorder, diabetes mellitus, atrial fibrillation, and other chronic conditions, was only documented as receiving showers on two occasions in July and none in August. The Minimum Data Set (MDS) assessment indicated the resident required staff assistance for bathing. Facility policy required residents to be scheduled for bathing two times per week, but documentation and staff interviews confirmed that this did not occur for the resident in question during the specified period.
Failure to Prevent Significant Medication Errors Due to Missed Doses and Documentation Discrepancies
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by multiple missed doses and discrepancies in medication administration. Medical record review, MARs, pharmacy delivery records, and staff interviews revealed that the resident, who had multiple diagnoses including dementia, atrial fibrillation, diabetes, and other chronic conditions, did not consistently receive prescribed medications such as diltiazem, sotalol, isosorbide, metformin, and oxycodone. There were several instances where medications were not available in the facility, and the MARs contained blank entries or indicated medications were not administered. Additionally, there were discrepancies where the MAR documented administration of medications that were not actually present in the facility, and the DON was unable to explain these inconsistencies. The resident was dependent on staff for medication administration and was cognitively impaired. During the period in question, the resident experienced an episode of altered mental status, abnormal vital signs, diaphoresis, numbness, and vomiting, which led to a transfer to the hospital. The review of progress notes indicated that the physician was not notified of the medication discrepancies, and there was no documentation of physician notification regarding missed or unavailable medications. The facility's own policy required documentation and explanatory notes when medications were withheld or not administered, but this was not consistently followed. Interviews with the DON and the resident's primary care physician confirmed that the facility did not have the required medications on hand during several periods, and the physician was not made aware of these issues. Pharmacy delivery records corroborated the gaps in medication availability, and controlled drug records showed that certain medications, such as oxycodone, were not refilled in a timely manner. The lack of communication and documentation, combined with the failure to ensure medication availability and accurate administration records, directly contributed to the deficiency.
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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 Waynesville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Austin Trace Health And Rehabilitation | 5.8 mi | ★★★★★ | 0 | 0 |
| Otterbein Springboro | 6 mi | ★★★★★ | 10 | 0 |
| St Leonard Hcc | 7.1 mi | ★★★★★ | 2 | 0 |
| Hillspring Health Care & Rehab | 7.4 mi | ★★★★★ | 0 | 0 |
| Bellbrook Health And Rehab | 7.5 mi | ★★★★★ | 21 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.