Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
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 Respiratory And Nursing Center Of Dayton during CMS and state inspections, most recent first.
Staff failed to perform hand hygiene during breakfast tray delivery and resident assistance. An Activities staff member and an Activities Director wore the same gloves while serving trays to multiple residents, and a CNA passed trays, moved personal items, repositioned residents, and provided feeding assistance without sanitizing hands between residents. The dishwasher sanitizer level was also below the required bleach range, and sanitation checks were not documented on two consecutive days.
Controlled medication counts did not match the reconciliation logs for five residents receiving Norco, oxycodone/Oxy IR, and lorazepam. During observation, pill cards showed quantities that differed from the documented counts, and an LPN stated she had forgotten to sign out doses at the time of administration; in one instance, a nurse mistakenly signed the log for the wrong resident.
Unlabeled opened neb solution packages were found for two residents, and staff could not determine how long the packages had been open. Surveyors also found expired famotidine and cetirizine in medication carts and rooms, and an LPN and RN verified the meds were expired and should have been removed from storage.
Failure to follow infection control precautions: staff did not maintain Enhanced Barrier Precautions for a resident with a Foley catheter, an LPN did not perform hand hygiene between medication passes for two residents, and a CNA did not follow contact precautions for a resident by entering the room without hand hygiene or PPE and providing care without gloves or a gown.
A resident with Alzheimer’s disease, dementia, and schizoaffective disorder bipolar type reported that a CNA would refuse to help her and give her attitude when she asked for assistance. The DON was notified, but the resident was only asked whether she felt abused and the allegation was not reported to the State Survey Agency as a possible neglect incident, despite facility policy requiring immediate reporting of abuse and neglect allegations.
Inaccurate MDS Smoking Assessment: The facility failed to ensure an MDS assessment accurately identified a resident’s smoking status. The resident, who had COPD, diastolic heart failure, residual schizophrenia, and oxygen dependence, was coded as a non-smoker even though the facility’s smoker list included the resident and a CNA confirmed the resident had smoked since admission. The MDS Nurse confirmed the incorrect coding.
Incomplete Care Plans for Multiple Residents: The facility failed to ensure comprehensive care plans addressed all aspects of care for three residents. One resident with severe cognitive impairment and multiple neurologic and respiratory diagnoses had no care plan interventions for hand contractures or ordered splints and palm protectors. Another resident with respiratory failure, paraplegia, and mental health diagnoses had no care plan for vision needs despite an optometry order for new eyeglasses, and a third resident with PTSD had no care plan for that condition.
Failure to assess and treat a resident’s hearing loss and ear pain. A cognitively intact resident with ESRD, CHF, parkinsonism, schizoaffective disorder, and DM2 reported right ear pain and decreased hearing, and was observed turning her head to hear with the left ear. Although Debrox otic drops were ordered for both ears, the record had no documentation of a provider ear exam, and the DON verified there was no evidence the ear had been assessed.
A resident with dysphagia, cognitive impairment, anemia, depression, DM2, bipolar disorder, and a feeding tube had an order for daily weights, but the record showed missed weights and inconsistent monitoring. The resident’s weight was documented in the 170-lb range before dropping to about 115 lbs, yet dietary notes described the weight as stable and did not explain the loss; the dietitians and DON could not account for the discrepancy and believed earlier weights may have been inaccurate.
A resident with DM2, schizophrenia, HTN, and anxiety was receiving Lantus SoloStar at bedtime, but blood sugar checks had been discontinued without documentation and were not being performed before insulin administration. The resident reported concern that staff were not checking his blood sugar, and the DON confirmed the last documented blood sugar result was months earlier. The manufacturer’s guide stated that blood sugar levels should be tested while using insulin such as Lantus SoloStar.
Failure to provide routine dental services to a resident with impaired dentition. The resident had Alzheimer's disease, dementia, and schizoaffective disorder, and the care plan identified oral health concerns related to missing and decayed teeth. The resident reported a loose tooth with intermittent pain and requested to see a dentist, but the record contained no documentation that routine dental services were provided or offered, as verified by the DON.
The facility failed to complete quarterly MDS assessments within the required timeframe for four residents, as per the RAI Manual guidelines. These residents, who had significant medical conditions and were dependent on staff for all ADLs, had their assessments completed beyond the 14-day limit after the ARD. This deficiency was confirmed by the Regional MDS Nurse.
A facility failed to provide adequate daily activities, including late afternoon and evening options, affecting a resident with multiple health conditions and potentially impacting others. Interviews and calendar reviews confirmed the lack of activities after early afternoon and on certain weekends, with no policies in place to address scheduling.
The facility failed to maintain food safety and sanitation, affecting 63 residents. Observations included uncovered food near debris, improper hand hygiene by staff, and an ice scoop stored directly in ice. These deficiencies were confirmed by staff interviews.
The facility failed to ensure proper infection control during tracheostomy care for a resident, as a respiratory therapist used a soiled dressing without changing gloves or performing hand hygiene. Additionally, staff did not wear appropriate PPE, including N-95 masks and eye protection, when entering the room of a COVID-19 positive resident, contrary to the facility's policy.
The facility failed to honor the preferences of a resident's representative for ADL assistance, as the resident was not transferred to a chair on the requested days. Additionally, another resident was unable to use the commode in his room due to a toilet riser, forcing him to use a different restroom. Staff interviews confirmed the lack of awareness and documentation of these preferences and needs.
A facility failed to complete a comprehensive admission MDS assessment within the required timeframe for a resident with severe medical conditions. The assessment, which should have been completed within 14 days of admission, was delayed by 25 days. This was confirmed by the Regional MDS Nurse, who stated that the facility adheres to the RAI manual guidelines.
A resident with chronic respiratory failure and dependence on a respirator pulled out her tracheostomy tube, leading to an emergency situation. Despite this known behavior, the care plan was not updated to include interventions. The oversight was confirmed by the MDS Coordinator and DON, highlighting a lack of policy on care planning.
The facility failed to provide adequate ADL care for two residents, leading to deficiencies. A resident with severe cognitive impairment was found with long, jagged fingernails and debris in her contracted hands, indicating a lack of nail care. Another resident, requiring extensive assistance for toileting, experienced a significant delay in receiving incontinence care, waiting approximately 49 minutes after activating her call light. Staff interviews revealed communication and coordination issues, and the facility lacked a written policy on call light response times.
A facility failed to properly position a dependent resident with severe medical conditions, including chronic respiratory failure and dependence on a ventilator. Despite a physician's order to place a pillow between the resident's hands and face to offload pressure, observations revealed the absence of the pillow, with the resident's chin pressed against her oxygen tubing. An LPN confirmed the non-compliance with the physician's order.
A resident with severe cognitive impairment and multiple medical conditions did not receive adequate care to prevent worsening contractures and limited ROM. Despite recommendations for a splint program, observations and staff interviews revealed the absence of splint application and documentation. The facility's restorative nursing policy was not effectively implemented, resulting in a deficiency in care.
A facility failed to provide trauma-informed care for a resident with PTSD. The care plan lacked interventions to manage PTSD triggers, and staff were not informed about appropriate responses. The resident's trauma history included military service and past abuse, with loud noises identified as triggers. Staff interviews confirmed a lack of knowledge and policy on trauma-informed care, resulting in the resident frequently becoming upset during care.
The facility failed to date opened vials of insulin and TB testing solution, affecting medication safety for two residents and potentially all residents. An LPN confirmed the vials were not dated, and the facility's policy requires proper dating and disposal of outdated medications.
The facility did not update the daily staffing information, as the posting dated 08/20/24 was still displayed on 08/25/24. The Administrator confirmed the posting should be updated daily, and there was no written policy for staffing postings.
Failure to Perform Hand Hygiene and Maintain Dishwasher Sanitation
Penalty
Summary
Staff failed to perform hand hygiene during meal service when passing breakfast trays and providing resident care. Activities #17 and the Activities Director #85 wore the same gloves while serving breakfast trays to Resident #19, Resident #28, and Resident #54 on the 100 Hall, and no hand hygiene was observed between residents. During interview, both staff stated they had washed their hands before putting on gloves and did not remove the gloves or perform hand hygiene until after passing the last meal tray; both were unaware that hand hygiene was required between residents. The facility policy titled Hand Hygiene stated hand hygiene would be performed before and after contact with residents. A CNA also passed breakfast trays, moved residents’ personal items to set up trays, assisted with repositioning, and provided feeding assistance to Resident #12, Resident #36, Resident #58, and Resident #71 without performing hand hygiene between residents. The CNA confirmed he had touched multiple residents and their personal items without washing or sanitizing his hands again until he was completely finished passing trays on multiple halls. In addition, the dishwasher sanitation level was found below the required range when checked with a test strip, and the sanitation log did not document checks on 06/27/26 or 06/28/26. The Dietary Supervisor confirmed the bleach level should be between 50 PPM and 200 PPM, while the facility documentation identified 13 residents who did not eat food prepared in the kitchen.
Controlled Medication Counts Did Not Match Reconciliation Logs
Penalty
Summary
The facility failed to ensure controlled medications available matched the number of controlled medications listed on the medication reconciliation logs for five sampled residents. During observation, discrepancies were identified between the pill counts on the medication cards and the quantities documented on the controlled medication reconciliation logs for residents receiving Norco, oxycodone/Oxy IR, and lorazepam. The report states that the controlled medication logs were not filled out correctly and should be reconciled at the time of administration. Resident #67 had diagnoses including chronic respiratory failure with tracheostomy status, oxygen dependence, major depressive disorder, moderate dementia with anxiety, and quadriplegia, and had an order for Norco 7.5-325 mg two tablets via G-tube every four hours as needed for pain; the card showed 23 pills while the log showed 24. Resident #65 had amyotrophic lateral sclerosis, respirator dependence, dementia, Raynaud's syndrome, traumatic brain injury, and a benign neoplasm of the meninges, and had an order for oxycodone 5 mg via G-tube every six hours as needed for pain; the card showed 21 pills while the log showed 22. Resident #14 had stage III chronic kidney disease, mild cognitive impairment, and unspecified secondary malignant neoplasm of the kidney and renal pelvis, with orders for Roxicodone 5 mg by mouth as needed and scheduled; the card showed six tablets while the log showed eight. Resident #55 had schizoaffective disorder, episodic panic disorder, generalized anxiety disorder, and mild cognitive impairment, with an order for lorazepam 0.5 mg daily; the card showed four tablets while the log showed five. Resident #33 had metabolic encephalopathy, chronic respiratory failure with hypoxia, major depressive disorder, COPD, CKD, and Alzheimer's disease, with orders for lorazepam 0.5 mg at bedtime and every two hours as needed; the card showed 16 tablets while the log showed 15, and staff stated one nurse had mistakenly signed the log after administering lorazepam to another resident.
Unlabeled opened meds and expired drugs found in storage
Penalty
Summary
Drugs and biologicals were not consistently labeled in accordance with accepted professional principles. On 06/29/2026 at 1:56 P.M., the Central Medication cart contained two opened foil packages of ipatropium-albuterol 0.5-2.5 (3 mg/ml) solution for Resident #5 that had no dates or labels, one package containing one vial and the other containing three vials. The same observation found an opened, undated, unlabeled foil package of ipatropium-albuterol 0.5-2.5 (3 mg/ml) solution for Resident #33 containing two vials. The foil packs stated that any unused vials were to be discarded within one week of opening, and LPN #19 verified the packages were not dated and that the length of time they had been opened could not be determined. The facility also had expired medications available in medication storage areas. From 1:52 P.M. to 2:17 P.M. on 06/29/26, surveyors observed one medication cart and two medication rooms containing nine unopened boxes of famotidine 20 mg tablets, each box with 25 tablets, that expired in April 2026, along with two opened bottles of cetirizine 10 mg tablets, each with 100 tablets, that expired in May 2026. LPN #19 and LPN #62 verified the famotidine and cetirizine were expired and should have been removed from shelves and carts and destroyed. Regional Nurse #125 later verified the facility had eight residents prescribed famotidine 20 mg tablets, though the medication was sent by the pharmacy in pill packs, and confirmed expired medications should be destroyed. The facility had no residents with active prescriptions for cetirizine 10 mg.
Failure to Follow Infection Control Precautions
Penalty
Summary
The facility failed to ensure Enhanced Barrier Precautions were followed for a resident with an indwelling Foley catheter and care plan interventions for enhanced barrier precautions. The resident had diagnoses including alcohol dependence with alcohol-induced persisting dementia, muscle weakness, hypertension, and obstructive and reflux uropathy. Although a sign for enhanced barrier precautions was posted outside the room, there was no PPE cart nearby. During catheter care, a CNA entered the room with gloves on but without a gown, and the CNA later confirmed a gown should have been worn and that PPE should have been available outside the door. The facility also failed to ensure hand hygiene was performed between residents during medication administration and failed to ensure contact precautions were followed for another resident. An LPN administered 25 medications to two residents without performing hand hygiene between them, and later stated she did not remember whether she sanitized her hands between the medication passes. In a separate observation, a CNA entered a resident’s room under contact precautions without sanitizing hands or donning PPE, handled the breakfast tray, rearranged items, fed the resident, adjusted the television, and helped reposition the resident in bed without gloves or a gown. The CNA later stated he did not know why the resident was on contact precautions and acknowledged he did not wear PPE while feeding or repositioning the resident.
Failure to Report Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect to the State Survey Agency for one resident. Resident #59, who had diagnoses including Alzheimer's disease, dementia, and schizoaffective disorder bipolar type, told the surveyor that a CNA with red hair would refuse to provide assistance and would give her attitude when she asked for help. The DON was notified of the statement and later asked the resident whether she felt abused; the resident said she was not abused. The DON stated she did not ask whether the resident's care was being neglected, and the facility did not initiate a Self Reported Incident with the State Survey Agency. The facility policy required immediate reporting of all allegations of abuse, neglect, exploitation, and mistreatment to the Ohio Department of Health.
Inaccurate MDS Smoking Assessment
Penalty
Summary
Ensure each resident receives an accurate assessment. The facility failed to ensure MDS assessments were accurate in the area of smoking for one resident out of four reviewed for smoking. The resident was admitted with diagnoses including chronic obstructive pulmonary disease, diastolic heart failure, residual schizophrenia, and dependence on oxygen. The MDS assessment identified the resident as cognitively intact and as a non-smoker, but the facility’s list of smokers included the resident. The MDS Nurse confirmed she marked the resident as a non-smoker on the MDS, and a CNA confirmed the resident had smoked since admission to the facility.
Incomplete Care Plans for Multiple Residents
Penalty
Summary
The facility failed to ensure that each resident had a comprehensive care plan that addressed all aspects of care needs for three residents sampled. Resident #2 had diagnoses including chronic respiratory failure with hypoxia, COPD, dependence on respirator, multiple sclerosis, contractures of the left hand and both upper arms, spastic hemiplegia and hemiparesis following cerebral infarction, bipolar disorder, and schizoaffective disorder. The most recent MDS showed severely impaired cognition and dependence for all ADLs. Physician orders dated 01/19/26 included a right hand/wrist splint at bedtime only and a left palm protector at bedtime only, but the current care plan initiated 01/10/25 only addressed assistance with ADLs related to multiple disease processes and did not include interventions for the contractures or the use of the hand splints and palm protectors. The DON confirmed the care plan did not include these interventions. Resident #12 had diagnoses including chronic respiratory failure with hypoxia, dependence on a respirator, generalized anxiety disorder, complete paraplegia, and major depressive disorder. The record showed optometry services through 360-Care on 10/20/25 with an order for new prescription eyeglasses, but there was no care plan addressing vision needs. Resident #12 stated she had an eye exam and was supposed to be getting glasses, and the Activities Director stated the resident had trouble seeing far away and had been seen by vision services, which issued a new order for glasses. Resident #3 had a diagnosis of PTSD, was cognitively intact on the MDS, and psychiatric notes documented anxiety, flashbacks, hypervigilance, and depression, but the care plan did not include PTSD. Social Services confirmed she created the care plans and that Resident #3 did not have a care plan for PTSD.
Failure to Assess and Treat Hearing Loss and Ear Pain
Penalty
Summary
The facility failed to assess and treat a resident’s hearing loss and ear pain. Resident #5 was admitted with diagnoses including end stage renal disease, dependence on renal dialysis, congestive heart failure, parkinsonism, schizoaffective disorder, and type 2 diabetes. The resident’s MDS identified her as cognitively intact and noted adequate hearing, with no difficulty in normal conversation, social interaction, or listening to TV. Physician orders dated 06/01/26 and 06/23/26 directed Debrox Otic Solution 6.5% to both ears for four days, then flush, but the medical record contained no documentation that a health care provider examined the resident’s ears. During interview, Resident #5 stated she had pain in her right ear, fluid in her right eye, and difficulty hearing from her right ear. She was observed turning her head so her left ear faced the surveyor in order to hear properly, and she confirmed she was doing so because she could not hear from the right ear. She stated this had started about a month earlier and believed it was an ear infection, although the ear drops had been ordered to remove ear wax. The DON verified there was no evidence that the resident’s ear had been assessed by a health care provider.
Failure to Monitor Ordered Weights and Significant Weight Loss
Penalty
Summary
The facility failed to adequately obtain daily weights as ordered and failed to monitor a resident’s weight loss and nutritional status for Resident #68, who had diagnoses including dysphagia, cognitive communication deficit, anemia, depression, type 2 diabetes, and bipolar disorder and was cognitively impaired. The care plan identified a potential for altered nutrition and hydration related to alternative nutrition via feeding tube, little desire to eat, age, and extended illness, with weights per protocol as an intervention. A physician order dated 04/03/26 required daily weights and notification of the physician for weight changes greater than 2.5 pounds in 24 hours or 5 pounds in a week, but the record showed weights only on 04/03/26, 04/04/26, and 04/09/26, with no other daily weights documented through 04/12/26. The resident’s weight was documented as 173 to 174.8 pounds in early May, then 115 pounds on 06/01/26, reflecting a 59-pound loss in 30 days and a 58-pound loss in 90 days. Despite this change, dietary progress notes described the resident as stable, with no significant weight changes, and stated no changes in diet or nutritional feedings were recommended. One note later stated the prior weights were likely incorrect because the geri chair may have been included, while another note still described the resident’s weight as relatively stable. During interviews, the dietitians could not explain the weight loss, and one stated the facility did not complete requested reweights until 06/10/26. Observation and interview with the DON confirmed the resident’s weight was 115.5 pounds, and the DON stated the initial weights were likely recorded incorrectly.
Failure to Monitor Blood Sugar Before Insulin Administration
Penalty
Summary
Resident #40, who had diagnoses including schizophrenia, hypertension, anxiety, and type 2 diabetes mellitus, was receiving Lantus SoloStar 23 units subcutaneously at bedtime. Review of the medication orders showed that an order for Accucheck blood sugar checks at bedtime for Lantus use had been discontinued on 11/10/25, and there was no documentation explaining why the blood sugar checks were stopped. Review of the June 2026 MAR showed the resident was still receiving Lantus at bedtime, with the last documented administration on 06/29/26. Review of the resident’s blood sugar records showed the last documented blood sugar result was on 11/09/25. The resident stated on 06/28/26 that staff had not been checking his blood sugar and he was concerned. The DON confirmed on 06/30/26 that the resident was not having blood sugar levels checked before receiving Lantus SoloStar daily and confirmed there was no documentation for discontinuing the Accuchecks. The manufacturer’s guide stated that blood sugar levels should be tested while using insulin such as Lantus SoloStar.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to provide routine dental services to one resident with impaired dentition. Resident #8 was admitted with diagnoses including Alzheimer's disease, dementia, and schizoaffective disorder, and the care plan identified the resident as at risk for oral problems because of natural teeth with some missing and some appearing decayed. The care plan called for complete oral assessments and referral to a dentist as needed. The resident's record included a progress note stating the resident reported a loose front left tooth and intermittent pain, and the resident later stated she had her natural teeth, was having pain, and wanted to see a dentist. Review of the medical record found no documentation that the resident was provided routine dental services, and the DON verified there was no documentation that dental services had been offered.
Untimely Completion of Quarterly MDS Assessments
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed in a timely manner for four residents, as required by the Resident Assessment Instrument (RAI) User's Manual 3.0. The manual stipulates that the completion date for quarterly MDS assessments must be no later than 14 days after the assessment reference date (ARD). However, the assessments for Residents #06, #08, #22, and #50 were completed beyond this timeframe. For instance, Resident #06's assessment with an ARD of 07/03/24 was completed on 08/05/24, and Resident #08's assessment with an ARD of 05/31/24 was completed on 06/24/24. The residents affected by this deficiency had significant medical conditions and dependencies. Resident #06 had diagnoses including chronic respiratory failure and multiple sclerosis, and was dependent on staff for all activities of daily living (ADLs). Similarly, Resident #08 had chronic respiratory failure and was also dependent on staff for all ADLs. The delay in completing the MDS assessments was confirmed by Regional MDS Nurse #110, who acknowledged that the facility used the RAI Manual for guidelines on completing these assessments. This deficiency affected four out of 23 residents reviewed for timely MDS assessments, with the facility having a total census of 75 residents.
Deficiency in Activity Scheduling for Residents
Penalty
Summary
The facility failed to provide daily activities throughout the day, including late afternoon and evening activities, affecting one resident directly and potentially impacting nine additional residents. The medical record for one resident revealed a history of conditions such as an unspecified fracture of the left femur, diabetes, anxiety, atrial fibrillation, and vascular disease. The resident's care plan indicated a preference for social activities, yet the facility did not meet these needs, as confirmed by the resident's interview, which highlighted a lack of weekend activities and early cessation of daily activities. Interviews with facility staff, including an Activity Aide and the Activity Director, confirmed the absence of activities after early afternoon and the lack of weekend activities every other weekend. The activity calendar for July and August 2024 corroborated these findings, showing no scheduled activities after 2:00 P.M., except for a weekly bible study, and no activities on certain Saturdays. The facility administrator confirmed the absence of policies regarding the scheduling of activities, contributing to the deficiency.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain food service safety and a sanitary environment, potentially affecting 63 residents who received food from the facility kitchen. During an observation, a Dietary Supervisor placed a small bin of cooked carrots on a prep table without covering them. The area above the carrots was covered with crumbs and debris, and an air conditioner nearby had a casing covered with dust and black specks. Additionally, there was a four-inch opening in the window next to the air conditioner, exposing the food to the outside environment. The Dietary Supervisor confirmed these observations during an interview. Further observations revealed lapses in hand hygiene practices. A staff member removed gloves, discarded them, and donned new gloves without performing hand hygiene. Another instance involved a Dietary Supervisor who, after removing gloves and lifting a garbage can lid, proceeded to stir gravy without washing hands. These actions were confirmed by interviews with the staff involved. Additionally, an ice machine in the dining room was found with a scoop stored directly in the ice, which was confirmed as improper by the Regional Dietitian.
Infection Control Deficiencies in Tracheostomy Care and COVID-19 Precautions
Penalty
Summary
The facility failed to ensure proper hand hygiene and infection control practices during tracheostomy care for a resident with severe cognitive impairment and multiple diagnoses, including chronic respiratory failure and a tracheostomy. During an observation, a respiratory therapist was seen using a soiled dressing to wipe around the tracheostomy site and did not change gloves or perform hand hygiene before inserting a new disposable inner cannula. This action was confirmed by the respiratory therapist, who acknowledged not following the facility's infection control policy, which requires hand hygiene and glove changes when moving from a contaminated to a clean body site. Additionally, the facility did not ensure that staff donned appropriate personal protective equipment (PPE) when entering the room of a COVID-19 positive resident. Despite the resident being under droplet isolation precautions, staff members entered the room wearing only surgical masks, gowns, and gloves, without the required N-95 masks and eye protection. Interviews with the involved staff and the infection preventionist confirmed the failure to adhere to the facility's COVID-19 prevention policy, which mandates the use of N-95 masks and eye protection in such situations.
Failure to Honor Resident Preferences and Needs
Penalty
Summary
The facility failed to honor the preferences of Resident #54's representative regarding the resident's activities of daily living (ADL) assistance. Despite a care conference where the representative requested that Resident #54 be transferred out of bed to a chair on Tuesdays and Thursdays, the facility did not comply. The ADL records showed that the resident was only transferred on three occasions, none of which were on the requested days. Interviews with staff, including a State Tested Nursing Assistant (STNA) and a Licensed Practical Nurse (LPN), revealed that they were unaware of the representative's request, and the Director of Nursing (DON) confirmed the lack of documentation for the requested transfers. Additionally, the facility did not accommodate Resident #49's needs regarding bathroom facilities. After returning from the hospital, Resident #49 was placed in a room with a toilet riser on the commode, which he was unable to use. As a result, he had to use the restroom in the shower room instead. Interviews with the resident and staff confirmed the presence of the toilet riser and the resident's inability to use the commode in his room independently.
Delayed Completion of Admission MDS Assessment
Penalty
Summary
The facility failed to ensure that comprehensive admission Minimum Data Set (MDS) assessments were completed in a timely manner, as required by the Resident Assessment Instrument (RAI) Manual. This deficiency affected one resident, who was admitted with multiple serious medical conditions, including chronic respiratory failure with hypoxia, sepsis, end-stage renal disease, anoxic brain injury, and a tracheostomy. The resident's admission MDS assessment, which should have been completed by the end of day 14 following admission, was not completed until 25 days after the assessment reference date. This delay was confirmed by the Regional MDS Nurse, who acknowledged that the facility follows the RAI manual guidelines for completing MDS assessments.
Failure to Update Care Plan for Resident with Tracheostomy
Penalty
Summary
The facility failed to update the care plan for a resident who had a history of pulling out her tracheostomy tube, which was a significant change in her condition. The resident, who had been admitted with chronic respiratory failure, dependence on a respirator, and other serious diagnoses, was found unresponsive after pulling out her tracheostomy tube. This incident was discovered by a respiratory therapist responding to a pulse oximetry alarm. Despite the resident's known behavior, the care plan had not been updated since April to include this behavior or any interventions for staff to follow. Interviews with the MDS Coordinator and the Director of Nursing confirmed the oversight and acknowledged the absence of a facility policy regarding care planning.
Deficiencies in ADL Care and Call Light Response
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care for two residents, leading to deficiencies in their care. Resident #50, who has chronic respiratory failure, dependence on a ventilator, and severely impaired cognition, was observed with long, jagged fingernails and debris in her contracted hands, indicating a lack of nail care despite regular bathing. This was confirmed by a Licensed Practical Nurse (LPN) who noted the resident's hands were contracted and dirty, highlighting a failure in maintaining proper hygiene for the resident. Resident #46, who requires extensive assistance for toileting due to conditions such as acute respiratory failure and heart failure, experienced delays in receiving incontinence care. Despite activating her call light, the resident waited approximately 49 minutes for assistance, during which time she was incontinent. Interviews with staff revealed a lack of communication and coordination, as one State Tested Nursing Aide (STNA) turned off the call light without providing care and another was unaware of the resident's needs. The facility lacked a written policy on call light response times, contributing to the delay in care.
Failure to Properly Position Dependent Resident
Penalty
Summary
The facility failed to ensure proper positioning of a dependent resident, which was identified during a survey. Resident #50, who has chronic respiratory failure, dependence on a ventilator, a tracheostomy, anoxic brain injury, and hypertension, was observed without a pillow placed between her hands and face as per the physician's order. This order, dated 10/17/22, was intended to offload pressure. Observations on two separate occasions revealed that the resident was lying in bed without the required pillow, and her chin was pressed against her oxygen tubing. An interview with an LPN confirmed the absence of the pillow, acknowledging the resident's contracted body and the existing physician's order.
Failure to Prevent Worsening of Contractures and Limited ROM
Penalty
Summary
The facility failed to provide adequate care and services to prevent the worsening of contractures and limited range of motion (ROM) for Resident #50. The resident, who was admitted with chronic respiratory failure, dependence on a ventilator, tracheostomy, anoxic brain injury, and hypertension, had severely impaired cognition and was dependent on staff for all activities of daily living. The resident's care plan identified risks related to impaired mobility and joint contractures. Despite receiving occupational therapy to maximize functional ROM and reduce the risk of contractures, the facility did not maintain a consistent splint program as recommended by therapy. Observations revealed that Resident #50 was not wearing splints, and interviews with staff confirmed the absence of documentation and application of splints to the resident's hands. The restorative flow records lacked specific instructions on splint application, and staff interviews indicated a lack of adherence to the recommended splint schedule. The facility's policy on restorative nursing, which aimed to maintain or improve residents' highest practicable level, was not effectively implemented for Resident #50, leading to the deficiency in care.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). The medical record review and staff interviews revealed that the care plan for the resident did not include interventions to eliminate or mitigate triggers of PTSD. The trauma assessment completed by the Social Services Designee noted the resident's military service, history of physical punishment, and unwanted sexual contact, with loud noises and music identified as potential triggers. However, the assessment lacked detailed information on how staff should manage these triggers. Interviews with staff, including the Social Services Designee, Minimum Data Set Nurse, Regional MDS Coordinator, Licensed Practical Nurse, and State Tested Nurse Aide, confirmed the absence of a policy on trauma-informed care and a lack of knowledge about interventions for the resident's PTSD. Staff members were unaware of the symptoms or appropriate responses if the resident experienced PTSD triggers, leading to routine incidents of the resident becoming upset and angry during incontinence care.
Failure to Date Opened Medication Vials
Penalty
Summary
The facility failed to ensure that open vials of insulin and tuberculin (TB) testing solution were properly dated after being opened, which is a requirement for safe medication administration. During an observation, it was found that the vials of Admelog insulin for Resident #44 and Insulin Lispro for Resident #60 were opened but not marked with the date of opening. This oversight was confirmed by an LPN, who was unable to determine when the vials had been opened. The manufacturer's instructions for both types of insulin indicated that the vials should be discarded 31 days after opening, but without the date of opening, compliance with this guideline could not be ensured. Additionally, the facility failed to date the Mantoux TB skin test solution vials after opening. Observations in the medication storage rooms on both the South and Central Units revealed that the TB skin test solution vials were opened but not dated. The LPN confirmed the lack of dating and was unable to ascertain when the vials had been opened. The facility's policy on medication storage required that medications and biologicals be stored according to the manufacturer's recommendations, and outdated items should be removed and disposed of properly. However, the failure to date these vials indicates non-compliance with this policy.
Failure to Update Daily Staffing Information
Penalty
Summary
The facility failed to ensure that daily staffing information was posted, including the date, census, and total numbers of actual hours worked per staff. This deficiency was observed when the daily staffing posting, dated 08/20/24, was still displayed on 08/25/24. An interview with the Administrator confirmed that the staffing posting at the front desk was outdated and should be updated daily. Additionally, the facility lacked a written policy regarding the staffing posting.
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What surveyors actually found near you
We read the 572 citations issued within 25 miles in the last 12 months — including the 4 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 Moraine
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Walnut Creek Nursing Center | 2.3 mi | ★★★★★ | 11 | 0 |
| Oaks Of West Kettering The | 3 mi | ★★★★★ | 10 | 0 |
| Laurels Of West Carrollton The | 3.2 mi | ★★★★★ | 7 | 0 |
| Vienna Springs Health Campus | 3.3 mi | ★★★★★ | 1 | 0 |
| Wood Glen Alzheimer's Community | 3.7 mi | ★★★★★ | 16 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 October 2026) and official state health department websites.