Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of October 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.
An agency CNA found a full code resident unresponsive, but an agency RN did not check for a pulse or vital signs and did not start CPR before leaving to call EMS and look for help. Staff present were not CPR certified, and EMS arrived to find the resident pulseless and apneic with no CPR started by the facility. The resident later died at the hospital.
A resident with encephalopathy and dementia, who required moderate assistance with showering and was scheduled for bathing twice weekly, did not receive documented showers for multiple extended periods despite no recorded refusals. The DON verified the missed showers, and the facility’s bathing choice policy stated residents are offered bathing twice a week and asked about their preferences.
Failure to Maintain Ordered Fall Interventions: A resident with severe cognitive impairment, dementia, and high fall risk had repeated falls while the ordered footwear intervention was not consistently in place. The resident was found wearing regular socks instead of non-skid socks during one fall, and later fell again while ambulating and attempting unsafe sitting on chair armrests. The DON confirmed the intervention was not in place at the time of the fall, and the resident sustained a head hematoma and a finger laceration during one of the incidents.
Falsified vital signs documented in a resident record. An agency RN charted pulse, BP, and respirations for a resident with multiple serious diagnoses, but security footage and DON review showed no vitals were taken during the shift because the RN did not have the vital sign machine. The RN later confirmed she did not take any vital signs despite documenting them.
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 Start CPR for Full Code Resident
Penalty
Summary
The facility failed to assess a resident for a pulse or vital signs and failed to immediately start CPR for a resident who was a full code and was found unresponsive. Resident #60 had diagnoses including multiple fractured ribs on the left side, acute respiratory failure with hypoxia and hypercapnia, type 2 diabetes mellitus with diabetic peripheral angiopathy, CHF, PVD, osteoarthritis of the left knee, and atherosclerotic heart disease of the native coronary artery. The resident’s code status was documented as full code, and the care plan stated CPR should be started and EMS called if needed. According to the CCTV timeline and staff statements, an agency CNA found the resident unresponsive during rounds and summoned nursing staff. An agency RN arrived at the room, briefly entered, and then left without taking vital signs, checking for a pulse, or starting CPR. The RN then went to the nurses’ station and made calls while the resident remained without CPR. Other agency CNAs were present, but they were not CPR certified. EMS arrived several minutes later and found the resident unresponsive, pulseless, and apneic, with no evidence that facility staff had started CPR before EMS arrival. The 911 audio, CAD log, EMS report, police report, and witness statements all reflected that the resident was found unresponsive and that the facility did not initiate CPR. The police officer reported staff were standing in the room and did not know what to do, and EMS reported the facility staff did not start CPR and did not know the approximate down time. The hospital record stated the resident had been found unresponsive by nursing facility staff, no CPR had been performed by the facility for over ten minutes, and EMS initiated CPR and ACLS during transport. The resident was later pronounced dead at the hospital.
Missed Scheduled Showers for a Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure Resident #46 received showers according to the resident’s bathing preference and the facility’s twice-weekly shower schedule. Resident #46 was admitted on 06/02/26 with diagnoses including encephalopathy, dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, altered mental status, thrombocytopenia, hypertension, and benign prostatic hyperplasia without lower urinary tract symptoms. The admission MDS dated 06/08/26 identified the resident as severely cognitively impaired and requiring moderate assistance with showering, and the ADL care plan dated 06/13/26 documented a self-care deficit related to encephalopathy and dementia, with one to two staff assistance needed for bathing and showering and a sponge bath when a full bath or shower could not be tolerated. Record review showed no documented refusals of showers, but shower sheets documented showers only on 06/12/26, 06/19/26, 07/10/26, and 07/14/26. The DON verified that Resident #46 had no documented showers during multiple date ranges between 06/02/26 and 07/30/26 and confirmed the resident was scheduled to receive showers two times per week. The facility’s resident centered care bathing choice policy stated residents are informed they will be offered bathing twice a week during admission and are asked if they have a different bathing preference.
Failure to Maintain Ordered Fall Interventions
Penalty
Summary
The facility failed to implement appropriate fall interventions for a resident with severe cognitive impairment and a high fall risk. The resident had diagnoses including Alzheimer’s disease, age-related physical debility, muscle weakness, gait and mobility abnormalities, and hypertension. A physician order required staff to ensure the resident wore non-slip socks or shoes while ambulating, and the care plan later included non-skid socks at all times and when ambulating. Despite these interventions, the resident was found after a fall on one occasion with regular socks in place rather than the ordered non-skid footwear. The resident experienced multiple falls during the review period. One fall occurred when staff had removed the resident’s shoes and the resident was wearing only socks; the resident slipped while being assisted back to bed and was lowered to the floor. Another fall occurred when the resident was exiting a room and stumbled to the floor, striking the head and sustaining a forehead hematoma and a laceration to the left fifth finger. A later fall occurred while the resident was ambulating in the common area and attempted to sit on the arm of a chair, resulting in the resident falling to the floor. The resident was also observed attempting to sit on chair armrests after the fall. The facility also failed to ensure a fall intervention was in place during the resident’s ambulation. The DON verified that the resident fell while wearing regular socks and confirmed that the non-skid sock intervention was not in place at the time of the fall. The DON also verified that education was provided on safe sitting after the resident’s later fall, despite the resident being severely cognitively impaired with dementia. The resident’s MDS showed dependence in multiple activities of daily living and one prior fall with no injury, and the fall risk assessment identified the resident as high risk for falls.
Falsified vital signs documented in resident record
Penalty
Summary
The facility failed to ensure one resident's medical record was accurate and free from falsified information. Resident #60 was admitted with diagnoses including multiple left rib fractures, falls, acute respiratory failure with hypoxia and hypercapnia, type 2 diabetes mellitus with diabetic peripheral angiopathy, CHF, PVD, left knee osteoarthritis, and atherosclerotic heart disease. The resident's admission MDS indicated the resident was cognitively intact. Review of the vital signs record showed Agency RN #142 documented a pulse of 66 beats per minute, blood pressure of 119/70 mmHg, and respirations of 18 breaths per minute at the same time on the evening of 07/11/26. Facility security footage reviewed with the DON showed that the RN came on shift that morning and entered the resident's room briefly on two occasions, but did not have the vital sign machine with her and there was no evidence that vital signs were taken. The DON verified that no staff present during the shift took the resident's vital signs, and the RN later confirmed by telephone that she did not take any vital signs during the entire shift despite documenting them in the record. The RN stated that if she did not have machinery, she did not like to palpate a pulse and said she always got a false pulse because she felt her pulse, but could see a pulse.
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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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
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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 | ★★★★★ | 8 | 0 |
| Otterbein Springboro | 6 mi | ★★★★★ | 9 | 0 |
| St Leonard Hcc | 7.1 mi | ★★★★★ | 1 | 0 |
| Hillspring Health Care & Rehab | 7.4 mi | ★★★★★ | 3 | 0 |
| Bellbrook Health And Rehab | 7.5 mi | ★★★★★ | 21 | 0 |
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