Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Riverside Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Failure to supervise two cognitively impaired residents allowed repeated sexually aggressive contact between them, including kissing, touching, and oral sex, while staff did not check on or redirect them for hours. One resident had severe cognitive impairment with dementia, and the other also had severe cognitive impairment with dementia, PTSD, and mood disorder. Neither resident had a care plan addressing sexually inappropriate behaviors at the time, and staff later confirmed the behavior continued after the incident.
Administrator Worked Without a Valid NHA License: The facility failed to ensure its interim NHA had a valid NHA license. Records from an employment agency and BELTSS showed the interim administrator used another NHA's license number to obtain the position, while BELTSS confirmed the individual was only registered as an AIT and did not hold an active NHA license.
Resident Council minutes showed no review of state or local advocacy group contacts, and an observation found no postings or available documents with that information on secured units. During a surveyor-led Resident Council meeting, three residents said they did not know the contact information and had previously had to ask staff for it, which made them feel uncomfortable due to possible retaliation. The Administrator and DON confirmed the contact information was not documented in the Resident Council meeting and was not available on the secured units.
Unsafe and Poorly Maintained Resident Rooms and Unit Conditions: A facility failed to maintain a clean, comfortable, and homelike environment for multiple residents. One resident had a toilet leaking onto the bathroom floor and into the room for weeks, a unit repeatedly smelled like urine, and several rooms had broken or unsafe conditions including an exposed light socket, a loose door handle, burned-out lights, short pull cords that residents could not reach, wall damage, missing curtain hooks, and large gashes behind a bed.
Resident Council concerns were not consistently addressed or resolved in a timely manner. Residents reported ongoing issues with food service, missing clothing, food condiments, and call light response times over several months, with no clear resolution documented in the grievance log. The AD confirmed concerns were relayed to dept heads but there was no evidence they were resolved by the next council meeting, and the Administrator acknowledged months without documented follow-up.
PASARR screening was not completed accurately for one resident on admission. The resident had diagnoses including PTSD and bipolar disorder, but the PASARR only documented panic or other severe anxiety disorder and stated there were no indications of serious mental illness or developmental disability. The Administrator confirmed the PASARR did not support the bipolar dx, and the facility policy required screening all individuals for SMI and ID/DD unless exempt.
Failure to care plan inappropriate sexual behaviors: Two residents with severe cognitive impairment and dementia were not care planned for inappropriate sexual behaviors. An LPN found one resident on her bed with her clothing disarranged while the other resident was in the room, and progress notes documented allegations that the residents attempted to engage in sexual contact. Interviews confirmed neither resident had a care plan addressing the behavior, and the facility investigation for possible sexual abuse was not provided to surveyors.
Failure to Obtain Ordered Weights: A resident with multiple medical conditions, including hemiplegia, COPD, an AKA, and CKD, had physician orders for weekly weights after readmission and monthly weights thereafter, but the record did not show the ordered weights were obtained. The last documented weight was 158 lbs, and a later note stated weight could not be obtained; the dietician reported the resident was at risk for weight loss and that the Hoyer lift scale was broken, preventing staff from weighing the resident.
Tube Feeding Supplies Not Replaced per Standards: A resident with a g-tube, severe dementia, Parkinson's disease, and psychiatric diagnoses had a Kangaroo pump bag at the bedside containing Jevity 1.5 that was dated beyond the 24-hour discard timeframe. An LPN confirmed the date and stated unused tube feeding solution should be discarded after 24 hours, while facility policy required tube feeding supplies to be changed daily and labeled and dated.
Failure to timely report an alleged resident-to-resident sexual abuse incident to the SA. An LPN found a resident in another resident’s room with her pants and underwear on the floor while the other resident stood nearby fully clothed. Both residents had severe cognitive impairment, and the record showed no proof of a completed abuse investigation. Staff later documented that the incident was not reported to ODH because a family member said nothing was seen on camera, and an incident report was not completed.
Failure to investigate alleged resident-to-resident sexual abuse. Two residents with severe cognitive impairment were found together in one resident’s room, with one resident on the bed with pants and underwear on the floor and the other standing fully clothed nearby. Staff later documented allegations that each resident was attempting to solicit the other to physically engage, but the facility could not provide proof of a completed investigation, and staff stated an incident report and SRI were not completed.
Failure to Administer Ordered Midodrine: A resident with ESRD on dialysis, COPD, right hemiplegia, and bipolar disorder had an order for Midodrine 2.5 mg PO q8h PRN for hypotension, with parameters to hold if SBP was above 110 and give if below 110. The MAR lacked documentation that the medication was given when BP readings were below the ordered threshold, and the NP confirmed the medication was not administered as ordered, including prior to dialysis.
A resident with severe cognitive and physical impairments, who required a Hoyer lift with two-person assistance for transfers, was manually transferred by a CNA without the required equipment or help. This improper transfer led to a left femoral neck fracture, requiring hospital admission and surgical repair. The CNA initially denied improper care but later admitted to the manual transfer, which was against facility policy and physician orders.
A resident with cellulitis and impaired skin integrity was observed with seeping fluids from unbandaged legs, creating unsanitary conditions in the facility. Staff struggled to manage the situation, leading to trails of fluid in common areas. The facility's infection prevention policy was not effectively implemented, as confirmed by the Administrator and DON.
The facility failed to maintain a safe, clean, and homelike environment for residents, as observed in multiple rooms. A resident's oxygen cannula was found on the floor with soiled items, another resident's bed was without sheets and had a shredded mattress with exposed wiring nearby, a third resident's toilet was clogged with exposed wires on the air conditioner, and a fourth resident's bed footboard was detached. These issues were confirmed by staff and are part of ongoing non-compliance.
Two residents were not treated with dignity and respect. One resident, severely cognitively impaired, was left in a common area inadequately dressed and with soiled items. Another resident, with a history of eating non-edible items, was seen chewing on a sock without staff intervention. Staff acknowledged these issues but cited convenience for their actions.
A facility failed to notify a resident's guardian and physician of significant changes, including a new roommate and a hospital transfer following a reported assault. The resident, with multiple health issues, was not on one-on-one supervision as expected. Documentation and staff interviews confirmed the lack of required notifications.
A facility failed to maintain food service safety standards when an STNA removed her N-95 mask and used her teeth to open a dressing packet for a resident with Alzheimer's and dysphasia. The STNA then handed the packet to the resident, contrary to the facility's infection prevention policy.
The facility failed to maintain a homelike environment, affecting several residents. Observations revealed issues such as a dangling outlet, rusted heaters, peeling paint, and torn blinds. Maintenance staff were aware but had not resolved these issues, indicating a lapse in communication or oversight.
The facility failed to provide adequate refrigeration for residents to store food brought in by family or visitors, affecting six residents. Residents reported no designated refrigerator for their use, and existing refrigerators were either full or for staff use. Observations showed unlabeled and undated items in a refrigerator, and the Dietary Manager confirmed the facility did not store outside food due to content uncertainty. The facility's policy allowed food from outside but did not ensure storage space availability.
A resident's rights were violated when the facility restricted his use of a motorized wheelchair and imposed supervised leave of absence requirements. Despite being cognitively intact, the resident's wheelchair was removed after an incident involving another resident, and he was not reassessed for its return. Additionally, the facility required supervision for leaving the building, despite a physician's order allowing unsupervised leave, without clear documentation or justification.
The facility failed to treat residents with dignity and respect, affecting three residents. A resident was told to return to her room when requesting shampoo, another was denied ice water outside scheduled times, and a third was led by the wrist by an STNA. These actions were inconsistent with the facility's policy on resident rights.
A cognitively intact resident, who required assistance for daily activities, was consistently woken up early against her preference due to facility scheduling. Despite expressing her dislike for early mornings, staff followed a supervisor's directive to get her up before the first shift. This deficiency was noted during a complaint investigation.
A resident with severe cognitive impairment and incontinence was not properly cleansed by an STNA during incontinence care. The STNA failed to clean the resident's genital and buttock areas, leaving the brief wet, contrary to the facility's policy. The STNA was unaware of the proper procedure and mistakenly believed hospice would provide care the next day.
A resident with cognitive impairment and medical conditions expressed severe pain during a dressing change, but the LPN did not assess or medicate the resident before the procedure. Despite the resident's repeated complaints and a policy emphasizing pain management, the LPN proceeded without addressing the pain, leading to a deficiency finding.
A resident with hemiplegia and hemiparesis was injured during a manual transfer by two STNAs, despite having orders for a Hoyer lift transfer. The lift was not working, leading to a manual transfer that resulted in a fracture to the resident's left humerus. The facility's policy required mechanical lifts for safety, but this was not followed, causing harm to the resident.
A resident in an LTC facility experienced significant medication errors due to transcription mistakes during admission. The resident's aspirin was omitted, lisinopril was given without necessary parameters, and methocarbamol was incorrectly transcribed as an as-needed medication. These errors were confirmed by LPNs and were not communicated to the physician, violating the facility's medication administration policy.
A facility failed to accurately document the administration of a resident's narcotic medications, resulting in discrepancies between the narcotic sign-out sheets and the Medication Administration Record (MAR). Interviews with the DON and nursing staff confirmed the documentation issues, despite the facility's policy emphasizing accurate documentation and adherence to the Five Rights of medication administration.
A facility failed to ensure a resident met criteria for admission to the secure unit and was in the least restrictive environment. The resident, who was cognitively intact and cooperative, was placed in the secure unit without displaying behaviors warranting such placement and without physician documentation or consent. The facility did not follow its policy requiring a mental and physical assessment and interdisciplinary team documentation.
Failure to Supervise Residents During Repeated Sexual Contact
Penalty
Summary
The facility failed to provide adequate supervision to prevent two cognitively impaired residents from repeatedly engaging in sexually aggressive behavior in one resident’s room. Review of electronic monitoring footage showed one resident entering the other resident’s room multiple times throughout the day, kissing her, touching her breast outside her shirt, attempting to touch her genital area, and later engaging in oral sex with her. Staff were not observed checking on the residents or redirecting the resident out of the room from the morning until late afternoon, when an LPN and CNA entered the room and found one resident on the bed with her pants and depends on the ground and the other resident standing in front of her. The resident whose room was involved had diagnoses including COPD, major depressive disorder, dementia, and anxiety disorder, and her quarterly MDS showed severe cognitive impairment with a BIMS score of 4. She required setup with eating, supervision with toileting and transfers, and partial assistance with dressing. The other resident had diagnoses including dementia, mood disorder, PTSD, and major depressive disorder, and his quarterly MDS showed severe cognitive impairment with a BIMS score of 7. He also required setup with eating and supervision with toileting, dressing, and transfers. Neither resident had a care plan in place addressing sexually inappropriate behaviors at the time of the incident. The record showed that after the room was entered by staff, the resident was redirected out of the room and the female resident was assisted with dressing and assessed, with no negative findings noted on skin checks. Progress notes later documented that both residents were allegedly attempting to solicit each other to physically engage, and staff interviews confirmed that the residents continued to have inappropriate sexual behaviors after the incident, including kissing and touching in common areas. Interviews also showed that staff and leadership did not complete an incident report or SRI at the time, and the facility did not initially report the allegation as resident-to-resident sexual abuse.
Administrator Worked Without a Valid NHA License
Penalty
Summary
The facility failed to ensure the Administrator had a valid Nursing Home Administrator (NHA) license. Review of documentation from an employment agency, documentation from the Board of Executives of Long-Term Services and Supports (BELTSS), an interview with the BELTSS Board Administrator, and a staff interview showed that interim NHA #630 was employed by the facility from 05/12/25 through 06/10/25. The Regional Director of Operations stated interim NHA #630 had been hired through an employment agency and that documentation provided to the facility showed an active NHA license. During the BELTSS review, the Board Administrator stated a concern had been raised about the validity of interim NHA #630's license and that an investigation determined interim NHA #630 had used the license number for NHA #700 to obtain a position as an NHA. The Board Administrator confirmed interim NHA #630 did not have a valid NHA license. Documentation from the employment agency showed interim NHA #630's date of birth was 10/23/73 and that the individual resided in Cincinnati, while BELTSS documentation showed NHA #700 had an active license number 7258, a different date of birth, and resided in Englewood. BELTSS records also showed interim NHA #630 was registered as an Administrator in Training and did not have an active NHA license.
Resident Council Lacked Access to Advocacy Contact Information
Penalty
Summary
The facility failed to ensure residents had access to the state and local advocacy organizations. Review of the monthly Resident Council Minutes from 08/15/24 through 07/07/25 showed no evidence that state or local advocacy group contact information was reviewed at monthly Resident Council meetings. Observation on 08/07/25 at 2:30 P.M. of the secured [NAME] and South units found no evidence of postings or available documents with state or local advocacy group contacts. During a surveyor-led Resident Council meeting on 08/05/25 at 2:06 P.M., Residents #128, #59, and #117 stated they did not know the contact information for state or local advocacy groups and said the information had not been reviewed in monthly Resident Council meetings. The residents also stated they had to ask staff for the contact information in the past, which made them feel uncomfortable due to possible retaliation. The Administrator confirmed on 08/05/25 at 2:44 P.M. that the contact information was not documented in the monthly Resident Council meeting, and the DON verified on 08/05/25 at 2:34 P.M. that the contact information was not available on the secured [NAME] and South units.
Unsafe and Poorly Maintained Resident Rooms and Unit Conditions
Penalty
Summary
The facility failed to ensure a clean, comfortable, and homelike environment for five of nine residents reviewed for environment. Resident #14, who was admitted with Parkinson's disease, schizophrenia, bipolar disorder, and hypertension and was cognitively intact per the quarterly MDS, was observed with water leaking from the toilet in the bathroom onto the bathroom floor, the room floor outside the bathroom, and to the threshold of the room to the hallway. The resident stated the toilet had been leaking for several weeks and staff were aware, and housekeeping confirmed the toilet had been leaking for "a while." The [NAME] Unit was observed to smell like urine on multiple occasions across several days, and housekeeping confirmed the odor. Resident #36's bathroom had a light hanging off the medicine cabinet with the light socket exposed, and the bathroom door handle was jiggly and about to fall off. Resident #20's room was dark because the overhead lights were burned out and the resident could not reach the short light string. Resident #65, who was bed bound, could not reach the short light string in the room; the wall behind the bed had gouges and the privacy curtain had missing hooks. Resident #112, who had dementia, anxiety disorder, and a cerebrovascular accident and was assessed with moderate cognitive impairment, had five gashes about 12 inches long behind the headboard of the bed, which the Maintenance Director verified.
Resident Council Concerns Not Timely Addressed
Penalty
Summary
The facility failed to ensure resident concerns raised in Resident Council meetings were addressed in a timely manner or resolved. Review of Resident Council Minutes from 08/15/24 through 07/07/25 showed repeated concerns involving missing clothing, multiple food complaints, food condiments, and call light response time. Review of the grievance logs showed multiple months with no documented follow-up to concerns raised in prior council meetings, including food concerns, missing clothing, and call light response time. The census was 164, and the deficiency affected three residents reviewed for Resident Council Meetings: #117, #59, and #128. During a surveyor-led Resident Council Meeting on 08/05/25, Residents #128, #59, and #117 stated they did not feel complaints were being addressed in a timely manner by administration. They reported that food service, food condiments, and missing clothing concerns had been ongoing for months without resolution, and that call lights were not being answered in a timely manner. The Activities Director confirmed the concerns were verbally relayed to department heads but stated there was no evidence the issues had been addressed or resolved by the next Resident Council meeting. The Administrator also confirmed there were months when resident concern resolutions were not documented in the grievance log and stated Resident Council concerns should be listed in the grievance log to show they had been resolved.
Inaccurate PASARR Screening on Admission
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed accurately upon admission for one resident. The resident was admitted with diagnoses including diabetes mellitus, hypertension, PTSD, bipolar disorder, and chronic kidney disease. A quarterly MDS assessment later showed the resident was cognitively intact and required varying levels of assistance with toileting, bed mobility, transfers, eating, and bathing. The resident’s PASARR, dated 10/10/24, documented panic or other severe anxiety disorder, but no other mental health diagnoses were indicated, and the PASARR notice stated there were no indications of serious mental illness and/or developmental disability. During interview, the Administrator stated Social Services were to review all resident PASARRs upon admission to ensure all mental health medical diagnoses were included, and confirmed the PASARR did not have documentation to support bipolar disorder. The facility policy stated all individuals must be screened for indications of serious mental illness and ID/DD unless they meet a hospital discharge exemption.
Failure to Care Plan Inappropriate Sexual Behaviors
Penalty
Summary
The facility failed to develop comprehensive care plans in a timely manner for two residents with severe cognitive impairment. Resident #160 was admitted with diagnoses including COPD, major depressive disorder, dementia, and anxiety disorder, and her MDS showed a BIMS score of four with needs for setup with eating, supervision with toileting and transfers, and partial assistance with dressing. Her care plan did not address sexually inappropriate behaviors, even though a progress note documented that an LPN found Resident #160 on her bed with her pants and underwear on the ground while Resident #49 was standing in front of her fully clothed, and the LPN escorted Resident #49 out of the room. Resident #49 was admitted with diagnoses including dementia, mood disorder, PTSD, and major depressive disorder, and his MDS showed a BIMS score of seven with needs for setup with eating and supervision with toileting, dressing, and transfers. His care plan also did not address inappropriate sexual behaviors. Progress notes documented that he was allegedly attempting to solicit Resident #160 to physically engage, and the facility investigation reviewed by surveyors did not provide proof of completion for possible sexual abuse. Interviews with the DON, MDS nurse, and unit manager confirmed that neither resident had been care planned for inappropriate sexual behaviors and that the incident involved both residents in Resident #160's room.
Failure to Obtain Ordered Weights
Penalty
Summary
The facility failed to monitor a resident’s weight as ordered. Resident #01 had an admission history that included left hemiplegia, COPD, a left above-the-knee amputation, and hypertensive heart and chronic kidney disease. After discharge to the hospital and readmission to the facility, the resident had a quarterly MDS assessment that indicated cognitive intactness and dependence on staff for toilet hygiene, bathing, and bed mobility. The record also showed physician orders for weekly weights for four weeks upon admission and then monthly weights. The medical record did not contain documentation that the ordered weights were obtained on the scheduled dates, and the last documented weight was 158 pounds. A later weight entry note stated that weight could not be obtained. During interview, the dietician stated the resident was at risk for weight loss due to multiple medical conditions and pressure ulcers, and that the resident’s weights were not obtained because the Hoyer lift scale was broken and staff did not have a way to weigh the resident. The facility policy stated that weekly weights were to be obtained for four weeks for baseline and monthly thereafter for stable residents unless otherwise indicated.
Tube Feeding Supplies Not Replaced per Standards
Penalty
Summary
The facility failed to ensure enteral feeding supplies were replaced according to professional standards for one resident receiving tube feedings. Resident #11 was admitted with diagnoses including Parkinson's disease, unspecified major depressive disorder, unspecified moderate dementia with psychotic disturbance, and generalized anxiety disorder. The resident's MDS indicated severely impaired dementia, self-directed behaviors, and no wandering or rejection of care. The care plan identified g-tube status and included interventions for medications via g-tube, flushes per protocol, placement and residual checks, and tube feeding as ordered. The resident had a physician order for Jevity 1.5 at 70 ml per hour for eight nocturnal hours. During observation, a Kangaroo pump bag was hanging at the bedside and contained a brown liquid labeled Jevity 1.5 with a date of 08/05/25. An LPN verified the bag was dated 08/05/25 and stated unused tube feeding solution should be discarded 24 hours after opening. The facility policy titled Enteral General Nutritional (tube feeding) Guidelines stated that syringes, tubing, and bottles used for tube feeding were to be changed daily and labeled and dated.
Failure to Timely Report Alleged Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to timely report an allegation of resident-to-resident sexual abuse to the State Agency and did not provide proof of completing an investigation for possible sexual abuse. On 04/28/25, an LPN entered Resident #160’s room and observed Resident #160 on her bed with her pants and underwear on the ground while Resident #49 was standing in front of her fully clothed. The LPN educated Resident #49 that he was not supposed to be in the room and escorted him to the common area. Resident #160 was assisted with getting dressed and a skin assessment was completed with no negative findings noted. Resident #160 had diagnoses including COPD, major depressive disorder, dementia, and anxiety disorder, and a BIMS score of four indicating severe cognitive impairment. Resident #49 had diagnoses including dementia, mood disorder, PTSD, and major depressive disorder, and a BIMS score of seven indicating severe cognitive impairment. Progress notes documented that both residents were allegedly attempting to solicit the other to physically engage, and the facility noted guardian notification and cognition concerns. During interviews, the DON stated the incident was not reported to ODH because the resident’s daughter said she did not see anything on the camera, and the UM/LPN stated the previous Administrator did not feel it was necessary to complete an SRI; an incident report was also not completed.
Failure to Investigate Alleged Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to timely investigate an allegation of resident-to-resident sexual abuse involving two residents. Resident #160 had diagnoses including COPD, major depressive disorder, dementia, and anxiety disorder, and her MDS showed severe cognitive impairment with a BIMS score of four. Resident #49 had diagnoses including dementia, mood disorder, PTSD, and major depressive disorder, and his MDS also showed severe cognitive impairment with a BIMS score of seven. Neither resident was care planned for sexually inappropriate behaviors or inappropriate sexual behaviors. On 04/28/25, an LPN entered Resident #160’s room and observed Resident #160 on her bed with her pants and underwear on the ground while Resident #49 was standing in front of her fully clothed. The LPN escorted Resident #49 out of the room and completed a skin assessment on Resident #160 with no negative findings. Progress notes later documented that Resident #160 was allegedly attempting to solicit Resident #49 to physically engage, and Resident #49 was allegedly attempting to solicit Resident #160 to physically engage. The facility did not provide proof of completing an investigation for possible sexual abuse, and staff interviews indicated an incident report and SRI were not completed and the event was not reported to ODH.
Failure to Administer Ordered Midodrine
Penalty
Summary
The facility failed to administer Midodrine as ordered for one resident reviewed for medication administration, resulting in a significant medication error. The resident was admitted with diagnoses including right hemiplegia, COPD, end stage renal disease with dialysis dependence, and bipolar disorder, and was documented as cognitively intact and dependent on staff for toilet hygiene, showers/bathing, transfers, and bed mobility. A physician order dated 11/30/24 directed Midodrine 2.5 mg by mouth every eight hours as needed for hypotension, to hold if systolic blood pressure was greater than 110 and administer if systolic blood pressure was less than 110. The record showed blood pressure readings of 97/50 on 06/03/25 and pre-dialysis blood pressures of 105/78 on 07/24/25, 106/64 on 07/31/25, and 104/67 on 08/05/25. The MARs for June, July, and August 2025 did not document Midodrine administration on those dates. During interview, the NP stated the order was supposed to be entered for Midodrine 2.5 mg every eight hours for hypotension, that the resident should have blood pressure checked three times per day, and that staff should have administered Midodrine as ordered prior to dialysis. The NP confirmed the facility had not administered the medication as ordered on those dates. The facility policy stated staff are to administer medication only as prescribed by the provider.
Improper Manual Transfer Resulting in Resident Fracture
Penalty
Summary
A deficiency occurred when a resident, who was severely cognitively impaired, legally blind, and had bilateral upper and lower extremity impairments, was transferred from bed to wheelchair without the use of a mechanical lift as required by their care plan and physician orders. The resident was fully dependent on staff for transfers and had an order specifying the use of a Hoyer lift with two-person assistance. Despite these documented requirements, a Certified Nursing Assistant (CNA) manually lifted the resident by placing his arms under the resident's legs and back, transferring the resident to a wheelchair without the mechanical lift or a second staff member present. Following this improper transfer, the resident began to display left hip pain and was subsequently assessed by a nurse practitioner. An X-ray revealed a non-displaced fracture of the left femoral neck, and the resident was admitted to the hospital for surgical repair. The CNA initially denied any concerns with care or transfers but later confessed to the improper transfer during the facility's investigation. The facility's policy clearly required the use of mechanical lifts with two staff members for such transfers, which was not followed in this incident.
Inadequate Infection Control Measures for Resident with Seeping Wounds
Penalty
Summary
The facility failed to maintain a safe and sanitary environment, as evidenced by the condition of Resident #128, who had multiple medical diagnoses including dementia, cellulitis, and impaired skin integrity. The resident was observed with seeping fluids from his legs, which were not consistently bandaged as per physician orders. This resulted in trails and puddles of fluid on the floor in the common areas and hallways, posing a potential risk to other residents. Observations on multiple occasions revealed that Resident #128's legs were leaking fluid, creating wet footprints and puddles in the facility. Staff members, including STNAs, were seen attempting to clean the fluids with inadequate methods, such as using bath blankets, which only spread the fluids further. The resident's guardian confirmed that the resident often removed his bandages, exacerbating the issue. Interviews with the facility's Administrator and Director of Nursing confirmed the ongoing issue with Resident #128's seeping legs and the challenges in keeping them bandaged. Despite attempts to use different types of wraps, the resident continued to unwrap them, leading to unsanitary conditions. The facility's infection prevention policy was not effectively implemented, as evidenced by the failure to maintain a clean environment and promptly address spills of body fluids, as recommended by CDC guidelines.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for its residents, as evidenced by several observations and interviews. Resident #10 was found with an oxygen nasal cannula lying on the floor, alongside dirty pants and a soiled incontinence brief with gnats flying around it. This was confirmed by an LPN. Resident #128's room was observed to have a bed without sheets, a dirty and shredded mattress with gnats, a gap between the mattress and headboard, and exposed wiring from a metal box on the wall. An LPN verified these conditions and noted the resident's incontinence and cellulitis infection. Resident #149's room had a clogged toilet with waste and toilet paper, and a missing thermostat control panel on the window unit air conditioner, exposing wires. The administrator attempted to fix the toilet but was unsuccessful. Resident #138's room had a footboard that had fallen off the bed and was lying on the floor, as confirmed by an LPN. These deficiencies were part of a continued non-compliance issue from a previous survey.
Failure to Maintain Resident Dignity and Safety
Penalty
Summary
The facility failed to treat residents with dignity and respect, affecting two residents. Resident #70, who was severely cognitively impaired and dependent on staff for activities of daily living, was observed in a common area wearing only a hospital gown that exposed part of his chest. His soiled wheelchair cushion was on the floor, and he had an incontinence brief and clothes hanging from his wheelchair handles, with no shoes or socks on. Staff members, including a registered nurse and a state-tested nurse aide, acknowledged the inappropriate situation but justified it as a convenience for staff to complete showers. Resident #73, who had impaired cognition and a history of eating non-edible items, was observed walking down the hallway with a non-skid sock hanging from his mouth, chewing on it. Several staff members, including a registered nurse, witnessed this behavior but did not intervene. The facility's policy on resident rights emphasizes providing care that meets the psychosocial, physical, and emotional needs of residents, yet the actions observed did not align with these principles.
Failure to Notify Guardian and Physician of Resident's Condition Change
Penalty
Summary
The facility failed to ensure timely notification of a resident's guardian and physician following a change in condition, affecting one resident out of three reviewed. The resident, who was mildly cognitively impaired and required supervision for activities of daily living, had multiple diagnoses including diabetes mellitus, hypertension, and schizoaffective disorder. The resident's guardian was not informed when the resident received a new roommate, nor when the resident was sent to the hospital after reporting a sexual assault and calling 911 due to stomach pain and a belief of pregnancy. The facility's documentation lacked evidence of notifying the guardian about the roommate change and the hospital transfer. The guardian was only informed of these events by external sources, such as the hospital emergency room. Additionally, the facility discontinued one-on-one supervision for the resident without notifying the guardian, contrary to what the staff had communicated. Interviews with staff and the Director of Nursing confirmed the absence of documented notifications, and a review of facility policies highlighted the requirement for such notifications, which were not followed in this case.
Infection Control Breach During Meal Service
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in the case of a resident with multiple diagnoses including Alzheimer's disease and dysphasia, who required supervision while eating. During a meal service in the main dining room, a State tested Nursing Assistant (STNA) removed her N-95 respirator and used her teeth to open a package of ranch dressing for the resident. The STNA then handed the opened dressing packet to the resident, who applied it to her salad. This action was confirmed in an interview with the STNA immediately following the observation. The facility's policy on infection prevention emphasizes the residents' right to a safe environment that minimizes infection risk, which was not upheld in this instance.
Facility Fails to Maintain Homelike Environment for Residents
Penalty
Summary
The facility failed to provide a homelike environment for its residents, as evidenced by several deficiencies observed during a survey. Seven residents were affected by various issues in their rooms, including a dangling electrical outlet, rusted heaters, peeling paint, scuffed walls, torn window blinds, and missing light bulbs. These conditions were observed during a series of inspections, and residents reported that maintenance issues had been previously communicated but remained unresolved. Interviews with the maintenance staff confirmed awareness of the problems, but there was a lack of action to address them. The maintenance man acknowledged the issues in the residents' rooms and mentioned that he believed his assistant was working on them, indicating a possible lapse in communication or oversight. These deficiencies were investigated under specific complaint numbers, highlighting the facility's non-compliance with providing a safe and homelike environment.
Inadequate Refrigeration for Resident Food Storage
Penalty
Summary
The facility failed to provide adequate refrigeration for residents to store food brought in by family or visitors, affecting six residents. Residents reported that there was no designated refrigerator for their use, and the existing refrigerators were either full or intended for staff use. One resident mentioned being reprimanded for having homemade lemonade stored in the kitchen, which she eventually had to discard. Another resident noted that while there was a refrigerator at the nursing station, it had limited space and residents were not allowed to have personal appliances in their rooms. Observations revealed that the refrigerator on the 100 hall contained meals, soda, and condiments, none of which were labeled or dated. The Dietary Manager confirmed that the facility did not store food from outside sources due to uncertainty about its contents. The facility's policy stated that residents could bring in food as long as safe storage guidelines were followed, but it did not ensure the availability of storage space. This deficiency was investigated under Complaint Number OH00157418.
Resident Rights Violation: Restriction of Mobility and Unsupervised Leave
Penalty
Summary
The facility failed to honor a resident's right to a dignified existence and self-determination by restricting the use of his electric wheelchair and limiting his ability to leave the building unattended. Resident #173, who was cognitively intact and his own person, had his motorized wheelchair removed after an incident where he allegedly ran over another resident's foot. Despite the resident's understanding of safety education and expressing a desire to have his wheelchair returned, the facility denied his request without documented reassessment or clear justification. The report details multiple incidents involving Resident #173, including an altercation in the dining room where he allegedly pinned another resident against the wall with his wheelchair. Witness statements and progress notes indicate that the resident's behavior was perceived as aggressive, leading to the removal of his motorized wheelchair. However, there was a lack of consistent documentation of ongoing behaviors that justified the continued restriction of his mobility rights. Additionally, the facility imposed supervised leave of absence restrictions on Resident #173 after he was found outside the building without signing out. Although the resident was cognitively intact and had a physician's order allowing unsupervised leave, the facility required supervision based on past incidents involving the motorized wheelchair. This decision was made without clear documentation or reassessment, further infringing on the resident's rights.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect, affecting three residents. Resident #153, who was cognitively intact, requested a bottle of shampoo from an LPN but was told to return to her room as there was no staff available to assist her. The resident expressed dissatisfaction with being frequently told to return to her room. The LPN admitted to telling the resident to go back to her room but could not explain why. Resident #143, who was moderately cognitively impaired, requested ice water but was informed by an LPN that ice water would only be provided at scheduled times. The resident was unable to access ice water independently due to a locked room and expressed dissatisfaction with the policy. The LPN stated that asking for ice water was considered a behavior of the resident, although this was not documented in the care plan. Resident #39, who had dementia and was rarely understood, was observed being led by the wrist by an STNA. The STNA admitted that this method of ambulation could be a dignity and respect issue.
Failure to Respect Resident's Choice in Wake-Up Time
Penalty
Summary
The facility failed to respect and facilitate the self-determination and choice of a resident, identified as Resident #27, who was cognitively intact and required assistance for daily activities. Despite her preference to not wake up early, the staff consistently got her up around 6:00 A.M. because she was on a list of residents who needed to be up before the first shift. This was confirmed through observations and interviews with both the resident and a State tested Nurse Aide (STNA) who stated that the resident disliked getting up early but was required to do so per the supervisor's instructions. The resident was observed asleep at the dining room table with her head on a pillow, indicating her discomfort with the early wake-up routine. This deficiency was identified during a complaint investigation.
Improper Incontinence Care for a Resident
Penalty
Summary
The facility failed to ensure proper incontinence care for a resident, identified as Resident #137, who was severely cognitively impaired and dependent on staff for activities of daily living, including toileting. The resident was always incontinent for bowel and bladder. During an observation, a State tested Nurse Aide (STNA) #309 was seen performing incontinence care on the resident. However, the STNA did not cleanse the resident's penis, scrotum, or buttocks, and the incontinent brief was left wet. This was contrary to the facility's policy for male perineal care, which requires thorough cleansing and drying of the perineal and rectal areas. The STNA admitted during an interview that she was unaware of the facility's policy for incontinence care and only performed a general cleansing because hospice was scheduled to shower the resident. However, a review of the medical record revealed that hospice was not scheduled to visit until the following day. This incident was identified as an incidental deficiency during a complaint investigation, affecting one of the three residents reviewed for incontinence care in a facility with a census of 170.
Failure to Provide Pain Management During Dressing Change
Penalty
Summary
The facility failed to provide appropriate pain management for a resident during a dressing change, which was identified as a deficiency. The resident, who was moderately cognitively impaired and dependent on assistance for mobility, expressed pain multiple times during the procedure. Despite the resident's repeated complaints of pain, the LPN did not assess the pain's location or intensity and did not medicate the resident before proceeding with the dressing change. The Director of Nursing was present and indicated that the resident would be medicated after the procedure, but this did not occur. The resident, who had medical diagnoses including Parkinson's disease and renal disease, rated his pain as a ten on a one to ten scale, indicating severe discomfort. The facility's policy on pain management emphasizes the importance of assessing and addressing pain based on the resident's report and clinical observations. However, this policy was not followed during the incident, as the LPN admitted to not assessing or medicating the resident due to nervousness. This oversight was discovered during a complaint investigation.
Failure to Use Hoyer Lift Results in Resident Injury
Penalty
Summary
The facility failed to provide appropriate supervision and assistance with resident transfers, resulting in actual harm to a resident. Resident #66, who had a diagnosis of hemiplegia and hemiparesis following a cerebral infarction, was ordered to be transferred using a Hoyer lift with the assistance of two staff members. However, on 06/03/24, two State Tested Nursing Assistants (STNAs) manually transferred the resident from a shower chair to her bed without using the Hoyer lift, as the lift was not working. During this manual transfer, the resident sustained a fracture to her left humerus. The incident was confirmed through interviews with the resident, the STNAs involved, and the Director of Nursing (DON). The resident reported hearing a pop in her left arm during the transfer, and subsequent medical evaluation confirmed a fracture. The facility's policy on mechanical lifts and transfers emphasized the importance of safety and required the use of two employees to perform lifts safely. Despite this policy, the manual transfer was conducted, leading to the resident's injury. The facility's failure to adhere to the prescribed transfer method and ensure the functionality of the Hoyer lift directly contributed to the incident.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically affecting one resident. The resident, who was admitted with chronic obstructive pulmonary disease and a pressure ulcer, had discrepancies in their medication orders upon admission. The preadmission paperwork indicated that the resident was to receive aspirin, lisinopril with specific parameters, and methocarbamol routinely. However, the admitting physician's orders omitted the aspirin, did not include the parameters for lisinopril, and incorrectly transcribed methocarbamol as an as-needed medication instead of a routine one. The Medication Administration Record showed that the resident did not receive aspirin for nearly two weeks, and lisinopril was administered without the necessary blood pressure and pulse checks until the parameters were added later. Methocarbamol was given as needed rather than routinely. Interviews with two LPNs confirmed these transcription errors and the lack of physician notification regarding the discrepancies. The facility's policy on medication administration was not followed, as medications were not administered as prescribed by the provider.
Failure to Document Narcotic Administration
Penalty
Summary
The facility failed to ensure accurate documentation of the administration of a resident's narcotic medications. Specifically, the medical record for Resident #802, who has diagnoses of paraplegia and thoracic spine pain, revealed discrepancies between the narcotic sign-out sheets and the Medication Administration Record (MAR). The narcotic sign-out sheets indicated that Oxycodone HCl Oral Capsules were administered on multiple occasions, but these administrations were not consistently documented in the MAR. This discrepancy affected the accurate tracking of 39 doses of Oxycodone for Resident #802 over a period from March to April 2024. Interviews with the Director of Nursing (DON) and nursing staff confirmed the documentation issues. The DON acknowledged being unaware of any narcotic issues and admitted that nurses were frequently reminded about the importance of documenting narcotic administration. Licensed Practical Nurse (LPN) #31 and Registered Nurses (RN) #80 and #110 described the process for administering and documenting narcotics, which includes checking the Electronic Medical Record (EMR), signing out the narcotic, administering it, and then documenting the administration and its effectiveness in the EMR. However, LPN #31 admitted to not documenting all administered doses in the EMR, although he denied any misappropriation of the medication. The facility's Medication Administration policy emphasizes the importance of accurate documentation and adherence to the Five Rights of medication administration. Despite this policy, the failure to document the administration of Oxycodone in the EMR for Resident #802 represents a significant lapse in compliance with the facility's procedures and regulatory requirements. This deficiency was identified during an investigation under Complaint Number OH00153299.
Failure to Ensure Resident Met Criteria for Secure Unit Admission
Penalty
Summary
The facility failed to ensure that a resident met the criteria for admission to the secure unit and was in the least restrictive environment available. The resident, who was cognitively intact with a BIMS score of 13 out of 15, was admitted to the secure unit despite not displaying any behaviors such as hallucinations, delusions, wandering, or exit-seeking that would warrant such placement. The resident was documented as being pleasant, cooperative, and compliant with care and medications, and there was no physician documentation indicating a benefit from residing in the secure unit. Additionally, the resident did not sign a consent to be in the secure unit, and a psychiatric consult conducted later confirmed the resident was alert, oriented, and without any acute psychosis or disturbance of perception. The facility's policy for the secure unit requires a mental and physical assessment documenting that the resident would benefit from such an environment, along with interdisciplinary team documentation that the secure unit is the least restrictive approach. However, the facility did not follow this policy, as there was no initial psychiatric consult or physician documentation supporting the resident's placement in the secure unit. The facility's failure to adhere to its policy and ensure the resident was in the least restrictive environment led to the deficiency identified in the report.
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 534 citations issued within 25 miles in the last 12 months — including the 1 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Dayton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aventura At Carriage Inn | 1.4 mi | ★★★★★ | 13 | 0 |
| Stonespring Of Vandalia | 1.4 mi | ★★★★★ | 0 | 0 |
| Siena Woods Care Center | 1.6 mi | ★★★★★ | 14 | 0 |
| Carecore At Mary Scott | 2.6 mi | ★★★★★ | 24 | 0 |
| Grafton Oaks Nursing Center | 2.7 mi | ★★★★★ | 16 | 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.