Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St Leonard Hcc during CMS and state inspections, most recent first.
The facility failed to ensure dependent residents received scheduled bathing services and that these services or refusals were properly documented. Several residents with conditions such as myelodysplastic syndrome, CKD, diabetes, encephalopathy, and osteoarthritis required assistance with ADLs and were care planned for staff-provided baths or sponge baths if full showers were not tolerated. Despite being scheduled for showers twice weekly, documentation over multiple months showed numerous missed bathing dates with no recorded showers or refusals. The ADON confirmed the twice-weekly shower schedule, the requirement for CNAs to report refusals to a nurse, and the need to document refusals, and verified that shower documentation was missing for these residents, contrary to facility policy that residents receive showers per request or per the facility schedule.
A resident with severe cognitive impairment and a history of wandering eloped from the facility after being left unsupervised when a CNA responded to another call. The resident exited through the front door while the wander guard system failed to alarm due to a temporary override, and was later found outside by another individual. The incident occurred despite care plan interventions requiring one-on-one supervision and use of a wander guard.
Two residents did not receive their prescribed medications because the required drugs were not available in the medication cart, resulting in a medication error rate above 5%. LPNs confirmed the unavailability, and the DON stated that certain medications, including aerosols and specific supplements, needed to be specially ordered and were not kept in stock.
Two residents experienced significant medication errors when one received overlapping doses of furosemide due to active duplicate orders, and another was given hydrochlorothiazide instead of the prescribed hydralazine after a nurse entered the wrong medication order. The errors were confirmed by the DON and did not follow the facility's medication administration policy.
A resident with multiple serious conditions had critical lab values that were not promptly communicated to the physician due to failed fax transmissions and delayed notification by staff. The LPN did not inform the on-call physician of these critical results while the resident was still present, contrary to facility policy requiring timely notification.
A resident with Alzheimer's disease was sent alone to a medical appointment without notifying the family or POA. The resident required supervision and assistance, but was left alone in the waiting area. Facility staff confirmed the oversight and acknowledged the lack of a policy for appointment scheduling and notification.
A resident with moderate cognitive impairment and a pressure ulcer on the left heel experienced deterioration of the wound and developed osteomyelitis due to the facility's failure to provide timely and appropriate care. Despite recommendations to float the heels and use off-loading boots, these interventions were not consistently implemented. Treatment delays and missed interventions were noted, and staff confirmed lapses in documentation and care implementation.
The facility failed to develop comprehensive care plans for two residents, one with vision and hearing impairments and another with an indwelling urinary catheter. Despite documented medical conditions and specific physician orders, the care plans lacked necessary documentation. This was confirmed by staff interviews.
A facility failed to timely update fall interventions in a care plan for a resident with severe cognitive impairment and multiple diagnoses, including dementia and chronic kidney disease. The resident experienced two falls, with interventions initiated but not promptly added to the care plan, as confirmed by the DON. The facility's policy required timely updates, which were not followed, leading to the deficiency.
The facility failed to implement physician treatment orders for two residents with skin conditions. A resident with a right hip surgical incision did not receive daily dressing changes as ordered, and another resident with lower extremity wounds did not have the prescribed wound care treatments initiated. These deficiencies were confirmed through observations and staff interviews.
A facility failed to follow physician orders for a resident's oxygen administration, setting the oxygen level higher than prescribed. The resident, with respiratory failure and COPD, was ordered to receive oxygen at two to three liters per minute, but observations showed it was set at 3.5 to four liters. This was confirmed by the ADON, who acknowledged the error.
A resident with major depressive and anxiety disorders required dental services for teeth extractions as per physician orders. Despite being cognitively intact and needing assistance with oral hygiene, the facility failed to schedule the necessary appointment, leading to ongoing pain for the resident. The Administrative Assistant/Scheduler was unaware of the need due to a lack of paperwork, contrary to the facility's Dental Services policy.
The facility failed to follow proper infection control protocols for two residents. A resident with impaired cognition and an infection risk did not receive wound care with the required gown usage by an LPN, who only wore gloves. Another resident received eye drops from an LPN who did not wear gloves, contrary to infection prevention guidelines.
The facility failed to offer influenza and pneumococcal immunizations to four residents, despite policies requiring these vaccines to be offered. The residents, with varying cognitive impairments and medical conditions, were not provided with the necessary immunizations or education, as confirmed by the DON.
The facility failed to offer COVID-19 vaccinations to three residents, despite their policy requiring it. These residents, with various medical conditions and cognitive impairments, had no documentation of being offered the vaccine or receiving education. The Director of Nursing confirmed the lack of immunization documentation.
Failure to Provide and Document Scheduled Bathing for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled bathing services and to document completed baths or refusals for multiple dependent residents. One resident with severe cognitive impairment and total dependence on staff for ADLs, including bathing, was care planned to receive staff-provided baths and had showers scheduled twice weekly in the evenings. Review of shower records over a three‑month period showed numerous dates with no documentation of showers being completed, and a family member reported that the resident did not receive baths on a consistent basis. Another resident with intact cognition but requiring assistance with ADLs, including bathing and dressing, also had twice‑weekly evening showers scheduled, yet the shower documentation showed multiple missed dates with no record of showers being provided. Two additional residents, both with intact cognition and requiring substantial or maximal assistance with bathing or showering, were care planned to receive staff assistance and sponge baths if they could not tolerate full baths or showers. One of these residents was scheduled for showers twice weekly on day shift, and the other was scheduled for showers twice weekly at night; in both cases, the shower documentation revealed multiple dates with no record of showers being completed. The ADON confirmed that residents are scheduled to receive showers twice weekly unless otherwise indicated, and stated that CNAs are to notify the nurse of refusals, that the nurse should re-offer the shower, and that any continued refusal must be documented. The ADON verified the missing shower documentation for all four residents, and facility policy stated that residents would be provided showers per request or per facility schedule protocols.
Failure to Prevent Elopement Due to Inadequate Supervision and Security System Lapse
Penalty
Summary
A resident with diagnoses of Alzheimer's disease, dementia, and traumatic brain injury, who was assessed as severely cognitively impaired and at risk for elopement, was admitted to the facility. The resident's care plan included interventions such as one-on-one supervision and the use of a wander guard device. On the day of the incident, the resident was left unsupervised when the assigned CNA left to answer another resident's call light. During this time, the resident exited the facility through the front door while emergency medical services were present for another resident, and the wander guard system did not alarm. The resident was discovered missing after a headcount and was later found outside on the facility grounds by an independent living resident. The facility's investigation revealed that the wander guard system could be temporarily disabled when the exit door code was entered or the unlock button at the receptionist desk was pressed, allowing the resident to leave undetected. Staff interviews and policy review confirmed that the resident did not receive the required supervision as outlined in the care plan, and the security system in place at the time allowed for this lapse in monitoring.
Medication Error Rate Exceeds Acceptable Threshold Due to Unavailable Medications
Penalty
Summary
The facility failed to ensure that medications were administered as ordered, resulting in a medication error rate of 7.41%, which exceeds the acceptable threshold of less than 5%. Two medication errors were observed out of 27 opportunities during medication administration. In the first instance, a resident with chronic obstructive pulmonary disease and osteoporosis did not receive their prescribed calcium 600 mg because it was not available in the medication cart. The LPN confirmed the medication was a special order and not in stock, and the DON verified that only calcium with vitamin D3 was available in the facility. In the second instance, another resident with Parkinson's disease and chronic obstructive disease did not receive their ordered budesonide-formoterol fumarate inhalation aerosol, as it was also not available in the medication cart. The LPN confirmed the medication was unavailable, and the DON explained that aerosol medications were not kept in stock and needed to be specially ordered. The facility's medication administration policy requires medications to be administered as ordered by the physician, but this was not followed in these cases.
Failure to Prevent Significant Medication Errors for Two Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by two separate incidents involving medication administration. For one resident with multiple complex diagnoses, including heart failure and hypertension, there were two overlapping physician orders for furosemide: one for 20 mg twice daily and another for 60 mg once daily. Both orders were active simultaneously, resulting in the resident receiving both dosages on two consecutive days before the orders were discontinued. The Director of Nursing confirmed that the previous order was not discontinued before the new one was started, leading to the resident receiving both medications concurrently, which should not have occurred. In another case, a resident with diabetes, schizophrenia, and other conditions was prescribed hydralazine for blood pressure management, but due to a nurse's error, hydrochlorothiazide was entered and administered instead. The error was discovered after several days, and the correct medication was then started. The nurse who made the entry error was identified, and it was confirmed that the wrong medication had been given. The facility's medication administration policy requires medications to be administered as ordered by the physician and in accordance with professional standards, but this was not followed in these instances.
Failure to Timely Notify Physician of Critical Lab Values
Penalty
Summary
The facility failed to notify the physician of critical laboratory values in a timely manner for one resident. The resident, who had multiple diagnoses including hyperkalemia, heart failure, and thrombocytopenia, had physician orders for laboratory tests such as CBC, BMP, and Digoxin levels. Laboratory results revealed several critical values, including a Digoxin level of 3.50 ng/mL (normal 0.8–2.0 ng/mL), BUN of 107 mg/dL, chloride of 82 mEq/L, and potassium of 7.0 mEq/L. The laboratory attempted to fax these results to the facility multiple times without success, and the facility ultimately received the results by fax the following morning. Staff interviews confirmed that the LPN did not receive the critical laboratory values by fax or phone until the laboratory called early the next morning. The LPN also verified that the on-call physician was not notified of the critical values while the resident was still in the facility. The facility's policy required timely notification of lab results to the physician or other practitioners, but this was not followed in this instance.
Failure to Notify Family of Resident's Appointment
Penalty
Summary
The facility failed to notify the family or Power of Attorney (POA) of a scheduled appointment for a resident with Alzheimer's disease, resulting in the resident being sent to the appointment alone. The resident, who was admitted with severe cognitive impairment and required supervision for ambulation and substantial assistance for toileting and transfers, was not accompanied to the appointment. The hospital's discharge instructions had indicated a follow-up appointment with a spine surgery clinic, but there was no documentation of this appointment in the physician orders or progress notes. Interviews with facility staff revealed that the administrative assistant and transportation staff did not inform the family or POA about the appointment and transportation arrangements. The transportation staff confirmed that the resident was left alone in the waiting area, despite having dementia and not being marked as needing an escort. The Director of Nursing acknowledged the oversight and confirmed that there was no policy in place for scheduling or notifying families of appointments. This deficiency was investigated under a specific complaint number.
Failure to Provide Timely Pressure Ulcer Care Leads to Osteomyelitis
Penalty
Summary
The facility failed to provide timely and appropriate care for a resident's pressure ulcer, leading to the deterioration of the wound and the development of osteomyelitis. The resident, who had moderate cognitive impairment and was dependent on staff for various activities, had a pressure ulcer on the left heel that was initially identified as a deep tissue injury. Despite recommendations to float the heels and use off-loading boots, these interventions were not consistently implemented. The treatment for the resident's pressure ulcer was delayed on multiple occasions. A new treatment ordered on May 21 was not applied until May 23, and there were missed treatments on June 3 and in July. Additionally, the treatment for osteomyelitis, diagnosed on June 14, was not started until June 28. Observations revealed that the resident's heels were not consistently floated off the mattress, and pressure off-loading boots were not used as recommended. Interviews with facility staff confirmed the lack of documentation and implementation of necessary interventions. The Assistant Director of Nursing acknowledged that the facility was behind in reviewing wound care recommendations and transcribing them into actionable orders. The physician expressed surprise at the progression of the wound to a stage IV and the development of osteomyelitis, indicating a significant lapse in the standard of care provided to the resident.
Deficiencies in Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was developed for two residents, addressing their specific medical needs. Resident #107, who was admitted with diagnoses including macular degeneration of the right eye and unspecified hearing loss, did not have a care plan that documented his vision and hearing concerns. Despite the resident's impaired cognition and self-reported issues with hearing and blindness in the right eye, the care plan lacked any mention of these conditions. This oversight was confirmed during an interview with the MDS Nurse, who acknowledged the absence of a care plan for the resident's hearing and vision issues. Similarly, Resident #95, who was admitted with a diagnosis of benign prostatic hyperplasia with lower urinary tract symptoms, had an indwelling urinary catheter with specific physician orders for its management. These orders included the use of a privacy bag, irrigation with normal saline, and the use of a leg bag when out of bed. However, the resident's care plan did not include any documentation regarding the management and care of the indwelling urinary catheter. This deficiency was confirmed by the Assistant Director of Nursing, who verified the lack of a care plan addressing the catheter care.
Failure to Timely Update Fall Interventions in Care Plan
Penalty
Summary
The facility failed to ensure that fall interventions were timely added to the care plan for a resident, which was identified during a review of records, staff interviews, and policy review. The resident in question, identified as Resident #66, was admitted with multiple diagnoses including dementia, congestive heart failure, and chronic kidney disease, among others. The resident had severely impaired cognition as noted in a quarterly Minimum Data Set (MDS) assessment. The resident experienced two falls, one on June 17 and another on June 21, with interventions such as placing Dycem in the wheelchair and a fall mat beside the bed being initiated but not promptly added to the care plan. The care plan for Resident #66 was revised on July 15, but the interventions were not added until July 10 and July 16, respectively, despite being initiated in June. This delay in updating the care plan was confirmed by the Director of Nursing during an interview. The facility's Fall Prevention Program policy, revised on July 17, stated that the care plan should be reviewed and updated as indicated, which was not adhered to in this case, leading to the deficiency.
Failure to Implement Physician Treatment Orders for Wound Care
Penalty
Summary
The facility failed to follow and implement physician treatment orders timely for two residents with un-pressure related skin conditions. Resident #60, who was admitted with diagnoses including orthopedic aftercare and vascular dementia, had a care plan for skin breakdown due to a right hip surgical incision. The physician's order required daily dressing changes, but during an observation, it was found that the dressing was three days old, indicating non-compliance with the prescribed treatment plan. Resident #108, admitted with hypertensive heart disease and severe cognitive impairment, had wounds on the lower extremities due to infection. The treatment plan included applying calcium alginate with silver and kerlix daily for 30 days. However, the physician orders for these treatments were not initiated, as confirmed by the Assistant Director of Nursing. This oversight resulted in the failure to provide the necessary wound care as prescribed.
Failure to Follow Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to adhere to physician orders for oxygen administration for a resident with acute and chronic respiratory failure, COPD, and other related conditions. The resident, who was cognitively intact and dependent on staff for daily activities, had a physician's order to receive oxygen at two to three liters per minute via nasal cannula to maintain oxygen saturation levels above 90%. However, observations on two consecutive days revealed that the resident's oxygen was set at higher levels, specifically between 3.5 to four liters per minute. This discrepancy was confirmed by the Assistant Director of Nursing, who acknowledged that the oxygen should not have been set that high, as per the physician's order and the facility's oxygen administration policy.
Failure to Schedule Dental Services for Resident
Penalty
Summary
The facility failed to schedule necessary dental services for a resident, as per physician orders, which resulted in a deficiency. The resident, who was cognitively intact and required substantial assistance with oral hygiene, had been admitted with diagnoses of major depressive disorder and anxiety disorder. Physician orders dated December 14, 2023, and February 21, 2024, indicated the need for teeth extractions and the preparation for dentures. Despite these orders, the facility did not coordinate the required dental appointment. The resident reported having broken teeth and experiencing pain, with no follow-up since a consultation in February 2024. An interview with the Administrative Assistant/Scheduler revealed that she was unaware of the need to schedule the dental appointment, as she had not received the necessary paperwork. The facility's Dental Services policy stated that routine and emergency dental services should be available according to the resident's assessment and care plan, but this was not adhered to in this case.
Infection Control Lapses in PPE Usage
Penalty
Summary
The facility failed to adhere to proper enhanced barrier precautions (EBP) for Resident #60, who had a diagnosis of infection and inflammatory reaction due to an internal joint prosthesis and significantly impaired cognition. During an observation, it was noted that a sign on the resident's door indicated the requirement for EBP, including gloves and gowns for high resident contact. However, during a wound treatment, LPN #107 only wore gloves and did not don a gown, despite assisting the resident with personal care and wound dressing. The LPN acknowledged the requirement for EBP but was unaware of the need for additional personal protective equipment beyond gloves. The Infection Control Preventionist confirmed that a gown was necessary for the procedure. Additionally, the facility failed to ensure that gloves were worn by LPN #110 when administering eye drops to Resident #26, who had a diagnosis of hemiplegia and hemiparesis following a cerebral infarction. The LPN administered Artificial Tears to the resident without wearing gloves, which was confirmed during an interview. These observations indicate a lapse in adherence to infection prevention protocols as outlined in the facility's policy.
Failure to Offer Immunizations to Residents
Penalty
Summary
The facility failed to ensure that influenza and pneumococcal immunizations were offered to residents, affecting four out of five residents reviewed for immunizations. Resident #19, who had severely impaired cognition and diagnoses including sequela of cerebral infarction and type two diabetes mellitus, was not offered the pneumococcal immunization, nor was there evidence of education provided to the resident or their representative. Similarly, Resident #51, with intact cognition and diagnoses of hemiplegia and hemiparesis following cerebral infarction, was not offered the pneumococcal immunization or provided with education. Resident #66, who had severely impaired cognition and diagnoses including dementia, congestive heart failure, and atrial fibrillation, was not offered either the influenza or pneumococcal immunization, nor was there evidence of education provided. Resident #74, with intact cognition and diagnoses of congestive heart failure, asthma, and major depressive disorder, was also not offered the influenza or pneumococcal immunization or provided with education. The Director of Nursing confirmed the lack of immunization documentation for all four residents. The facility's policies stated that influenza and pneumococcal vaccines should be offered to residents, but these were not adhered to in these cases.
Failure to Offer COVID-19 Vaccinations to Residents
Penalty
Summary
The facility failed to ensure COVID-19 immunizations were offered to residents, affecting three out of five residents reviewed for immunizations. Resident #19, who was admitted with diagnoses including type two diabetes mellitus and hypertensive heart disease with heart failure, had severely impaired cognition according to the Minimum Data Set (MDS) assessment. There was no evidence in the medical record that the facility offered the COVID-19 vaccine or provided education to the resident or their representative. This lack of documentation was confirmed by the Director of Nursing during an interview. Similarly, Resident #66, admitted with diagnoses such as dementia, congestive heart failure, atrial fibrillation, and pulmonary hypertension, also had severely impaired cognition. The medical record showed no evidence of the COVID-19 vaccine being offered or education provided. Resident #74, with diagnoses of congestive heart failure and asthma and intact cognition, also lacked documentation of being offered the vaccine or receiving education. The facility's policy stated that COVID-19 vaccinations should be offered unless medically contraindicated, already immunized, or refused, but this was not adhered to for these residents.
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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 Centerville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bethany Village | 2.1 mi | ★★★★★ | 0 | 0 |
| Bellbrook Health And Rehab | 2.2 mi | ★★★★★ | 21 | 0 |
| Centerville Health And Rehab | 2.6 mi | ★★★★★ | 5 | 0 |
| Oak Creek Terrace Inc | 2.8 mi | ★★★★★ | 3 | 0 |
| Centerville Post Acute | 3 mi | ★★★★★ | 2 | 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.