Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Scarlet Oaks Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to store and serve food according to professional standards, affecting all 65 residents. Observations revealed unlabeled and undated food items, uncovered utensils with debris, and staff without beard restraints during meal preparation. The Dietary Manager was unaware of certain labeling requirements, and the Administrator expected compliance with cleanliness and policy adherence.
The facility failed to inform residents about their right to formulate an advance directive, affecting three residents. Despite having a policy to provide written information on advance directives, the facility did not adhere to it, as evidenced by the lack of documentation and acknowledgment in residents' records. Interviews with staff revealed that the facility did not offer assistance or information about advanced directives, focusing only on code status discussions.
A resident with severe cognitive impairment and other medical conditions was discharged from hospice care, but the facility failed to complete a Significant Change in Status Assessment (SCSA) within the required 14-day period. The MDS Coordinator was not informed of the discharge, leading to a deficiency identified during a survey. The facility's policy requires an SCSA when hospice services are discontinued, but this was not followed.
The facility failed to develop and implement comprehensive care plans for four residents, leading to deficiencies in their care. A resident receiving supplemental oxygen lacked a corresponding care plan, another with PTSD had no interventions for their condition, a resident with a language barrier had no communication assistance in their care plan, and a resident with multiple pressure ulcers had incomplete wound care documentation. Staff interviews confirmed these oversights, highlighting a lack of adherence to facility policies.
The facility failed to monitor weights for two residents at nutritional risk, leading to unaddressed significant weight loss. A resident with severe cognitive impairment and tube feeding was not weighed upon admission or consistently thereafter, resulting in a 30.1-pound weight loss. Another resident, also with severe cognitive impairment, was not weighed after admission despite orders for weekly weights. Staff interviews revealed a lack of adherence to the facility's weight assessment policy, impacting the ability to monitor and address residents' nutritional needs.
A resident with Alzheimer's disease was receiving supplemental oxygen without a physician's order, contrary to facility policy. Observations and staff interviews confirmed the lack of documentation for the oxygen therapy, highlighting a failure to follow established procedures for respiratory care.
A facility failed to maintain proper infection control during tracheostomy care for a resident with chronic respiratory failure. The RT did not clean the bedside table or use a barrier, contaminating the sterile field. The RT also used a non-absorbent box as a trash container and failed to change gloves or perform hand hygiene between tasks, compromising infection control practices.
A resident with chronic respiratory issues and moderate cognitive impairment reported abuse by a night shift nurse to an NP, who delayed reporting the incident to facility management. This resulted in late notification to the state agency, violating the facility's policy for immediate reporting of abuse allegations.
The facility failed to implement adequate infection control measures, including the absence of a Legionella filter on a handwashing sink and insufficient handwashing stations for residents under Enhanced Barrier Precautions. Additionally, a phlebotomist did not follow PPE protocols when caring for a resident with C. Auris, increasing the risk of infection spread.
The facility did not maintain water temperatures within the required range, impacting all 62 residents. Observations showed that the water temperature at the only operational handwashing sinks in the third and second-floor shower rooms were 84 and 91.6 degrees Fahrenheit, respectively. These findings were confirmed by a maintenance assistant, despite the facility's policy requiring water temperatures between 105 and 120 degrees Fahrenheit.
A facility failed to provide timely eating assistance to dependent residents, affecting five individuals. Meal trays arrived, but by later observation, several residents had not received their meals. Only two CNAs were available to assist seven residents, while other staff were occupied with different duties, leaving some residents without necessary help.
The facility failed to provide adequate staffing for timely meal assistance, affecting several residents who required help with eating. Despite having two CNAs on the third floor, additional staff were unavailable to assist, resulting in delayed meal service for residents, including one who was severely cognitively impaired and dependent on staff for eating.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to ensure food was stored and served in accordance with professional standards for food safety, potentially affecting all 65 residents. During an initial tour of the kitchen, it was observed that a 5-pound bag of frozen tater tots and a 16-ounce bag of broccoli were not in their original packaging and lacked labels or use-by dates in the walk-in freezer. Additionally, a 5-pound container of peanut butter was opened but not labeled with the date it was opened, and four containers of spices were opened without use-by dates or opened dates. Furthermore, serving utensils were found uncovered with food crumbs and debris. During meal service observations, two male employees with facial hair were not wearing beard restraints while preparing food. The Dietary Manager (DM) was unaware of the requirement for beard restraints and stated that he was not informed about labeling items with opened dates. The facility's policy required all foods to be covered, labeled, and dated, and staff to wear hair restraints. The Administrator expected the kitchen to be clean and policies to be followed, noting that the health department had visited two months prior.
Failure to Provide Information on Advance Directives
Penalty
Summary
The facility failed to inform and provide written information to residents regarding their right to formulate an advance directive. This deficiency affected three residents who were reviewed for advanced directives. The facility's policy required that residents or their representatives be provided with written information about their rights to accept or refuse medical or surgical treatment and to formulate an advance directive. However, the facility did not adhere to this policy, as evidenced by the lack of documentation and acknowledgment of providing such information to the residents. Resident #51, who had a medical history of chronic respiratory failure, atrial fibrillation, and other conditions, was found to have no advanced directive available for review in their medical record. Interviews with the Director of Nursing (DON) and Social Services Director (SSD) revealed that the facility did not provide forms or discuss advanced directives with residents or their families. The SSD only documented the residents' code status choices in the progress notes, without offering information or assistance regarding advanced directives. Similarly, Resident #63, with severe cognitive impairment, and Resident #16, with severe impairment in cognitive skills, also lacked documentation of advanced directives or acknowledgment of information being provided. Interviews with facility staff, including the Admissions Director and Administrator, confirmed that the facility did not offer assistance or information about advanced directives to residents or their families. The facility's failure to comply with its policy and provide necessary information about advanced directives led to this deficiency.
Failure to Complete SCSA After Hospice Discharge
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident who was discharged from hospice care. The resident, identified as #48, had a history of severe cognitive impairment, vascular dementia, and other significant medical conditions. The resident was receiving hospice care from June 2024 until November 2024. However, after being discharged from hospice care on November 26, 2024, the facility did not complete the required SCSA within the mandated 14-day period. The MDS Coordinator, responsible for completing MDS assessments, was not informed of the resident's discharge from hospice care until the survey team brought it to the facility's attention. The MDS Coordinator stated that typically, such changes would be communicated during clinical meetings or via email to the interdisciplinary team, but this did not occur in this instance. The Director of Nursing and the Administrator both expressed expectations that MDS assessments should be completed accurately and on time, including the completion of an SCSA when a resident is discharged from hospice care. The facility's policy, aligned with the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, mandates that an SCSA be performed when a resident discontinues hospice services. Despite this requirement, the facility did not adhere to the policy, resulting in a deficiency. The failure to complete the SCSA was identified during a survey, highlighting a lapse in communication and adherence to assessment protocols within the facility.
Deficiencies in Care Plan Implementation
Penalty
Summary
The facility failed to ensure comprehensive person-centered care plans were developed and implemented for four residents, leading to deficiencies in their care. Resident #6, who had a history of Alzheimer's disease and required assistance with activities of daily living, was observed receiving supplemental oxygen without a corresponding care plan or physician's order. Interviews with staff confirmed the oversight, as the oxygen therapy was not documented in the resident's care plan, contrary to the facility's expectations and policies. Resident #11, diagnosed with post-traumatic stress disorder (PTSD), did not have a care plan addressing their PTSD diagnosis. Despite the resident's history of trauma and the need for follow-up care, the care plan lacked focus, goals, or interventions related to PTSD. Staff interviews revealed a lack of awareness about the resident's PTSD, and the MDS Coordinator admitted unfamiliarity with PTSD interventions, resulting in the omission from the care plan. Resident #60, who had a language barrier and cognitive communication deficit, did not have a care plan addressing the communication challenges identified upon admission. The resident's inability to speak English hindered effective communication, as noted in multiple progress notes. The care plan failed to include interventions to assist with communication, and staff interviews highlighted the oversight. Additionally, Resident #63, with multiple pressure ulcers, had a care plan that only addressed one ulcer, neglecting the others. The Director of Nursing and MDS Coordinator acknowledged the need for individual wound care plans, but the care plan remained incomplete.
Failure to Monitor Resident Weights
Penalty
Summary
The facility failed to ensure that residents at nutritional risk had their weights monitored according to policy, affecting two residents. Resident #60, who had a history of severe cognitive impairment and required tube feeding due to dysphagia, was not weighed upon admission or consistently thereafter. The Director of Nursing (DON) acknowledged that the process was for weights to be obtained on admission and weekly for four weeks, but this was not followed. The resident experienced a significant weight loss of 30.1 pounds, which was not communicated to the Registered Dietician (RD) or addressed by the staff. Resident #63, who also had severe cognitive impairment and was at risk for nutritional imbalance, was not weighed after admission despite having an order for weekly weights. The RD noted that the facility had ongoing issues with obtaining and recording weights, which hindered her ability to monitor and address residents' nutritional needs. The Assistant Director of Nursing (ADON) and DON were unaware of the lack of weight monitoring for Resident #63, and the facility's failure to follow standard practices for weight monitoring was evident. Interviews with staff, including Licensed Practical Nurses (LPNs) and the RD, revealed a lack of communication and adherence to the facility's weight assessment policy. The policy required weights to be recorded and significant weight changes to be retaken and reported, but this was not consistently done. The facility's failure to obtain and document weights as required led to missed opportunities to identify and address potential health issues related to weight loss in residents.
Failure to Obtain Physician's Order for Supplemental Oxygen
Penalty
Summary
The facility failed to ensure that staff obtained a physician's order for the use of supplemental oxygen for Resident #6, who was one of two residents reviewed for oxygen therapy. Resident #6, who had a medical history of Alzheimer's disease and a BIMS score indicating moderate cognitive impairment, was observed receiving supplemental oxygen via nasal cannula at a flow rate of 2 liters per minute. However, a review of the resident's care plan and order summary report revealed no evidence of a physician's order for the administration of supplemental oxygen. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed that the process for administering supplemental oxygen required obtaining a physician's order prior to administration, except in emergencies. The facility's policy on oxygen administration also stipulated the need for a physician's order. Despite these protocols, Resident #6 was receiving oxygen therapy without the necessary documentation, indicating a lapse in following established procedures for safe and appropriate respiratory care.
Infection Control Deficiency in Tracheostomy Care
Penalty
Summary
The facility failed to maintain appropriate infection control practices during tracheostomy care for Resident #51, who was admitted with chronic respiratory failure and tracheostomy status. The resident, with moderate cognitive impairment, was dependent on staff for all activities of daily living and required tracheostomy care every shift. During an observation, Respiratory Therapist (RT) #19 did not clean the bedside table or place a barrier before placing supplies on it, contaminating the sterile field. RT #19 used a non-absorbent box as a trash container and failed to perform hand hygiene or change gloves between clean and dirty tasks. RT #19's actions included placing contaminated items on a sterile field, using dirty gloves to handle a new sterile inner cannula, and failing to maintain separation between clean and dirty tasks. The Director of Nursing expressed expectations for proper infection control practices, including keeping clean and dirty separate, changing gloves, and washing hands between tasks. The report highlights the failure to adhere to these practices, which are essential to prevent infection during tracheostomy care.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to implement its policy for immediate reporting of abuse allegations, resulting in a delay in notifying the state agency. A nurse practitioner (NP) was informed by a resident of alleged abuse by a night shift nurse, including verbal abuse, kicking, and pinching, but did not report the incident immediately. The NP was informed of the abuse on 12/31/24 but delayed reporting it to the facility management until 01/03/25, citing the holiday and the resident's inability to recall the nurse's name as reasons for the delay. This delay led to the facility notifying the state agency outside the required timeframe. The resident involved had a history of chronic respiratory failure, epilepsy, and other significant medical conditions, and was dependent on a ventilator. The resident had moderate cognitive impairment and was at risk for falls and injuries. The facility's policy required immediate reporting of abuse allegations, defined as within two hours for physical abuse, but this protocol was not followed. The administrator was unaware of the initial report to the NP and believed the incident was reported within the required timeframe, highlighting a breakdown in communication and adherence to policy.
Inadequate Infection Control Measures for Legionella and C. Auris
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were in place, specifically regarding the prevention of Legionella and Candida Auris (C. Auris) infections. Observations revealed that a handwashing sink on the third floor did not have a filter to prevent the spread of Legionella, despite a presumptive positive healthcare-associated case being reported. The Local Health Department had instructed the facility to implement water use restrictions or use point-of-use filters, but the facility did not comply fully, as evidenced by the unfiltered sink in the third-floor shower room. Additionally, the facility did not provide adequate handwashing stations for residents under Enhanced Barrier Precautions (EBPs), affecting 24 residents. The water supply to handwashing sinks in resident rooms was turned off, and only gallon jugs of water were provided, which was deemed inappropriate for hand hygiene, especially in the context of C. Auris cases. The facility had only two handwashing stations with filters, located in employee bathrooms, which was insufficient given the number of residents and staff requiring access to proper handwashing facilities. Furthermore, a phlebotomist failed to adhere to the required personal protective equipment (PPE) protocols when caring for a resident with C. Auris. The phlebotomist did not wear a gown and did not perform hand hygiene after drawing blood from a resident in EBPs, subsequently proceeding to another resident's room without changing PPE. This action violated the facility's enhanced barrier precautions policy, which mandates the use of gloves and gowns during high-contact resident care activities to prevent the spread of multidrug-resistant organisms.
Inadequate Water Temperature Maintenance
Penalty
Summary
The facility failed to maintain water temperatures within the appropriate range, affecting all 62 residents. During an observation, the water temperature at the only operational handwashing sink in the third-floor shower room was recorded at 84 degrees Fahrenheit, and the second-floor shower room sink was at 91.6 degrees Fahrenheit. These temperatures were verified by Maintenance Assistant #79. According to the facility's safety policy dated December 2009, water heaters servicing resident rooms, bathrooms, common areas, and shower areas should be set between 105 and 120 degrees Fahrenheit.
Failure to Provide Timely Assistance with Eating
Penalty
Summary
The facility failed to provide timely assistance with eating to dependent residents, affecting five out of nine residents who required such assistance. On the day of observation, meal trays arrived on the third floor at 11:59 A.M., but by 12:34 P.M., five residents had not received their meal trays. This delay was observed despite the facility's policy stating that residents should receive assistance with meals in a manner that meets their individual needs. Interviews with staff revealed that the third floor had seven residents dependent on staff for eating assistance, but only two CNAs were available to assist them. Additional staff, including the scheduler, medical records staff, and two nurses, were supposed to help but were unavailable due to other duties. Specifically, the LPNs were occupied with medication pass and other nursing responsibilities, leaving the CNAs overwhelmed. As a result, Resident #42's meal tray remained on the cart without assistance, highlighting the facility's failure to meet the needs of its residents.
Inadequate Staffing Leads to Delayed Meal Assistance
Penalty
Summary
The facility failed to maintain adequate staffing levels to ensure timely meal assistance for residents requiring help with eating. Specifically, five residents did not receive their meal trays on time due to insufficient staff on the third floor. The facility had only two CNAs assigned to assist seven residents who were dependent on staff for eating assistance. Despite the presence of additional staff members, such as the scheduler and medical records staff, they were unavailable to assist with feeding. Resident #42, who was severely cognitively impaired and dependent on staff for eating, was one of the affected residents. Observations revealed that Resident #42's meal tray remained on the cart for an extended period, indicating a delay in receiving assistance. Interviews with CNAs and LPNs confirmed the staffing inadequacy, as the LPNs were occupied with other duties and unable to assist with feeding. The facility's policy required that residents receive meal assistance in a manner that meets their individual needs, which was not adhered to in this instance.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Cincinnati
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Seven Acres Senior Living At Clifton | 1.4 mi | ★★★★★ | 1 | 0 |
| Clifton Healthcare Center | 1.5 mi | ★★★★★ | 2 | 0 |
| Astoria Place Of Cincinnati | 1.5 mi | ★★★★★ | 13 | 0 |
| Garden Park Health Care Center | 1.6 mi | ★★★★★ | 28 | 0 |
| Twin Towers | 2.4 mi | ★★★★★ | 3 | 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 June 2026) and official state health department websites.