Below average — CMS composite of the measures below.
A standard survey is most likely before around September 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 St. Theresa Care Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to maintain kitchen plate-warming equipment and did not serve hot foods at the required temperature of at least 135°F. Only one side of the plate warmer was operational for several months, and a test tray showed entrée and side dishes in the 112–114°F range and not hot when tasted. Multiple residents reported that meals were not hot enough or were cold, and meeting minutes from resident groups documented ongoing complaints about hot foods being served cold, indicating a persistent problem with food temperature control.
The facility failed to ensure a dignified dining experience for three cognitively impaired residents on puree diets who required staff assistance with eating. During a lunch meal, a CNA stood while feeding all three residents seated at the same table, rather than sitting at eye level as required by facility policy. The CNA acknowledged she should have been seated but stated she stood so she could reach all three residents, and the DON confirmed that standing over residents during feeding was a dignity concern and inconsistent with the facility’s feeding practices policy.
A cognitively intact resident with multiple medical conditions, including Type II diabetes and anxiety disorder, alleged that an LPN threatened to harm her under his breath and reported this to both the police and the Administrator. Despite a facility policy requiring prevention of further potential abuse during an investigation, the LPN was allowed to continue working and complete the shift on another floor after the allegation was made. Time records confirmed the LPN remained on duty through the night, and the Administrator later acknowledged that the LPN was not immediately removed from duty because she did not feel he was a threat.
A resident was unable to access personal funds outside of standard business hours and on weekends, as confirmed by staff interviews and facility policy review. The facility's process limited fund access to weekdays, and the policy lacked guidance for after-hours or weekend withdrawals, resulting in delayed access for the resident.
The facility did not timely report multiple allegations of physical and emotional abuse to the State Survey Agency as required. In one case, a resident with chronic pain reported staff were rough during repositioning, but the DON treated it as a care issue rather than abuse and did not report it until the family raised concerns at the hospital. In another case, two residents were involved in a physical altercation, which was documented internally but not reported to the State Survey Agency. Staff interviews revealed confusion about reporting requirements, leading to the deficiency.
A resident with chronic pain and intact cognition reported that staff were rough during repositioning, but the DON treated the report as a care grievance rather than an abuse allegation. As a result, the staff involved were not immediately suspended and continued working in the facility until the hospital later notified the facility of the abuse allegation, prompting an investigation.
A facility failed to ensure proper hand hygiene during wound care for a resident with a Stage IV sacral ulcer. An RN changed gloves without sanitizing hands between handling soiled and clean body sites, contrary to CDC guidelines. The resident had multiple diagnoses and required extensive assistance.
The facility failed to timely implement their approved water management plan to prevent a Legionella outbreak. A resident diagnosed with Legionella pneumonia during a hospital stay was readmitted to the facility, but there was a delay in installing required filters on showers and sinks. Despite the approval of the water management plan, the facility did not install shower filters until three months later and sink filters even later, potentially putting residents at risk.
Failure to Maintain Equipment and Serve Hot Foods at Required Temperatures
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure hot foods were served at palatable, appetizing, and safe temperatures in accordance with facility policy. Kitchen observations showed the plate warmer equipment was not fully functional, with only one side of the hot plate pellet system in service and able to hold about 30 plates. Staff interviews confirmed the plate warmer had been nonfunctional for several months, and both a staff member and the Dietary Manager stated they were unaware of any pending repairs. The facility’s written policy, “Temperatures of Safe Food Handling” (2023), required all hot foods to be served at 135°F or higher, and the Dietary Manager stated hot foods should be at least 135°F when served. A test tray observation of a lunch meal showed hot food items below the required temperature, with chicken at 112°F, potatoes at 113°F, and carrots at 114°F, and the food was not hot when tasted. Multiple residents reported that meals were not hot enough or were cold when served. Resident interviews documented ongoing complaints about food temperature, and review of Food Committee and Resident Council meeting minutes from prior months showed residents had previously voiced concerns that hot foods were being served cold. The deficiency was cited as noncompliance under Complaint Number 2665253 and had the potential to affect all residents except two who did not receive food from the kitchen.
Failure to Provide Dignified Dining Assistance in Memory Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure a dignified dining experience for three residents on the memory care unit who required staff assistance with eating. All three residents had dementia, severely impaired cognition per their MDS assessments, and were on puree diets; two were documented as dependent on staff for eating, and one required staff assistance. During a lunch meal observation in the memory care dining room, the three residents were seated at the same table with their meal trays in front of them while a CNA provided eating assistance. Surveyors observed that the CNA stood while assisting all three residents with eating rather than sitting at eye level as required by the facility’s “Resident Dignity and Feeding Practices” policy. In interview, the CNA confirmed she was standing and acknowledged she should sit beside residents when assisting with eating, explaining she stood because she could not reach all three residents if seated. The DON also confirmed that the CNA should have been seated while providing eating assistance and stated that standing over residents during feeding was a resident dignity concern, consistent with the facility’s policy that staff should sit at eye level with residents during feeding.
Failure to Remove LPN From Duty After Verbal Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to prevent potential abuse after an allegation of staff-to-resident verbal abuse. A cognitively intact resident with diagnoses including lack of coordination, Type II diabetes, and anxiety disorder reported that an LPN threatened to harm her under his breath. The resident, who required varying levels of assistance with ADLs such as eating, hygiene, toileting, and bathing, contacted both the police and the Administrator to report the alleged verbal abuse. A police report documented that the resident called law enforcement in the evening and officers arrived later that night. The facility’s self-reported incident and subsequent investigation materials showed that the Administrator spoke with the resident, the LPN, and the responding police officer on the date of the allegation. Despite the allegation and the facility policy requiring prevention of further potential abuse while an investigation is in process, the LPN remained on duty and completed his shift on another floor. Timecard records confirmed the LPN worked through the night and clocked out the following morning. The Administrator acknowledged that the LPN was not immediately removed from duty after the allegation because she did not feel he was a threat, which was inconsistent with the written policy stating the facility shall prevent further potential abuse while the investigation is ongoing.
Failure to Provide Resident Access to Personal Funds Outside Business Hours
Penalty
Summary
The facility failed to ensure that residents had access to their personal funds outside of normal business hours and on weekends. Interviews with staff revealed that residents could only access their personal funds Monday through Friday, from 8:00 A.M. to 5:00 P.M., and were unable to obtain money on weekends. The Business Office Manager and receptionists confirmed these restricted hours, and the facility policy did not specify procedures for accessing funds after hours or on weekends. A resident with intact cognition reported previous difficulties in obtaining money, stating it typically took at least three days to receive requested funds and that they did not attempt to access funds outside business hours because they knew it was not possible. The Administrator stated an expectation that residents should have access to their funds seven days a week, but this was not reflected in practice or policy. This deficiency was identified during a complaint investigation and affected at least one resident reviewed for personal funds.
Failure to Timely Report Allegations of Abuse to State Survey Agency
Penalty
Summary
The facility failed to timely report allegations of physical and/or emotional abuse to the State Survey Agency as required by policy and regulation. In one instance, a resident with rheumatoid arthritis, chronic pain syndrome, and fibromyalgia, who was cognitively intact, reported to the DON that night shift staff were rough when repositioning them. The DON treated this as a care grievance rather than an abuse allegation, due to the resident's history of pain, and did not report it as abuse. It was only after the resident's family raised concerns to hospital staff days later that the facility reported the allegation to the State Survey Agency. In another case, a resident with Alzheimer's disease and dementia was struck on the head with an eyeglass case by another resident with severe cognitive impairment. The incident was documented, and the physician, family, and management were notified, but the facility did not report the physical abuse allegation to the State Survey Agency. Interviews revealed that staff and management were unclear about reporting requirements, particularly in cases involving altercations between cognitively impaired residents. Facility policy required immediate reporting of all alleged violations to the Administrator, state agency, and other authorities within specified timeframes. Despite this, the facility did not report three separate abuse allegations involving three residents to the State Survey Agency as required. Staff interviews confirmed a lack of understanding and inconsistent application of reporting protocols, contributing to the deficiency.
Failure to Immediately Protect Resident Following Allegation of Staff-to-Resident Abuse
Penalty
Summary
The facility failed to immediately protect a resident from alleged staff-to-resident physical abuse after the resident reported that staff were rough during repositioning. The resident, who had diagnoses including rheumatoid arthritis, chronic pain syndrome, and fibromyalgia, and was cognitively intact, reported to the DON that night shift staff were rough with them. The DON treated the report as a grievance related to care rather than an abuse allegation, and did not immediately suspend the staff involved or initiate an abuse investigation at that time. The staff members identified in the allegation continued to work in the facility and were not suspended until several days later, after the hospital notified the facility of the abuse allegation made by the resident's family. Facility policy required immediate action to protect residents from harm and to suspend alleged perpetrators pending investigation. Despite this, the staff members named in the allegation continued to work in the facility between the initial report and the later notification from the hospital, although they did not work directly with the resident during that period. The deficiency was identified through staff interviews, record reviews, and policy review, and was found to affect one resident reviewed for abuse.
Improper Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure proper hand hygiene was practiced by staff during wound care for a resident. During an observation of wound care for a resident with a Stage IV sacral decubitus ulcer, a registered nurse removed soiled gloves and donned new gloves without sanitizing or washing her hands. This occurred while the nurse was transitioning from handling a soiled body part to a clean body site, which is against the guidelines for hand hygiene. The resident involved had multiple diagnoses, including a severe sacral ulcer, depression, pulmonary embolism, and osteomyelitis, and required extensive assistance with activities of daily living. The facility's new hire orientation guidelines and CDC recommendations clearly state that hand hygiene should be performed before moving from a soiled area to a clean area on the same patient. However, these guidelines were not followed during the observed wound care procedure.
Failure to Timely Implement Water Management Plan for Legionella Prevention
Penalty
Summary
The facility failed to timely implement their approved water management plan to potentially prevent a Legionella outbreak. Resident #84, who had a history of diabetes mellitus, illicit drug use, respiratory failure, and pneumonia, was diagnosed with Legionella pneumonia during a hospital stay. Upon readmission to the facility, the positive Legionella test results were noted in the hospital records, and the facility reported the case to the local health department and the state agency. However, there was a delay in installing filters on the showers and sinks as per the approved water management plan. Shower filters were not installed until three months after the recommendations, and sink filters were not installed until a later date, despite the ongoing use of sinks by staff and residents. Observations revealed that 64 shower filters were in place, but no sink filters were noted. The Environmental Specialist confirmed that the facility's water management plan, approved by the Ohio Department of Health and the Local Health Department, included installing filters on showers and sinks. The facility began testing for Legionella on 11/01/23 and hired an outside consultant. Despite the approval of the water management plan on 12/15/23, the facility delayed the installation of the necessary filters, potentially putting residents at risk. The facility's policy stated that they would work to inhibit microbial growth in the water system to reduce the risk of Legionella, but this was not timely implemented as required.
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Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
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| Indianspring Of Oakley | 0.5 mi | ★★★★★ | 0 | 0 |
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| Deupree Cottages | 2 mi | ★★★★★ | 0 | 0 |
| Arc At Cincinnati | 2 mi | ★★★★★ | 38 | 0 |
| Madeira Healthcare Center | 2.8 mi | ★★★★★ | 1 | 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.