Above average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Triple Creek Retirement Community during CMS and state inspections, most recent first.
A resident with toxic encephalopathy, Parkinson’s disease, and a gastrostomy, who was cognitively impaired and dependent for toileting and dressing, had active orders and a care plan requiring Enhanced Barrier Precautions (EBP) with gown and glove use during high-contact ADL care, toileting, and linen changes. Surveyors observed a CNA repeatedly entering and exiting the resident’s room, which was posted for EBP, without wearing a gown while providing perineal care, toileting assistance, dressing, and changing bed linens. The CNA acknowledged the resident was on EBP, that no PPE supply was available near the room, and that she did not wear a gown, contrary to the facility’s EBP policy requiring gowns and gloves for such high-contact care.
A resident experienced a significant medication error due to a failure in the medication administration process. The report does not provide further details about the circumstances or the resident's condition.
Staff did not promptly inform a resident, their physician, and a family member about important events such as injury, decline, or room changes, resulting in a failure to meet notification requirements.
A resident admitted with encephalopathy did not have their admission MDS assessment completed within the required timeframe, as the assessment was finalized 15 days after entry instead of within the mandated 13 days. Staff interviews revealed a lack of clear policy and inconsistent knowledge regarding MDS assessment timing requirements.
A resident did not receive a required quarterly MDS assessment within the mandated 92-day interval. Review of records showed that the assessment was missed, and interviews with the MDS Coordinator and other staff confirmed the omission, with no explanation provided for why the assessment was not completed on time.
A tube feeding formula bag in use for a resident with significant medical needs was found unlabeled during observation. Nursing staff reported that labeling stickers often failed to adhere, and in this case, the required information was not present on the bag. The ADHS confirmed that facility policy required labeling of tube feeding bags with resident and formula details, which was not done.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
A resident with cerebral palsy and dysphagia, dependent on tube feeding, was found to have an IV pole used for enteral feedings that remained visibly dirty with brown, sticky spots over several days. Facility staff acknowledged the equipment was unclean and confirmed there was no cleaning schedule or policy for multi-use equipment.
The facility failed to document a resident's meal intake during their stay, despite the resident being on a specific diet and the facility's policy requiring such documentation. The DON confirmed the lack of documentation.
Failure to Use Required PPE for Resident on Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program by not ensuring proper use of personal protective equipment (PPE) for a resident on Enhanced Barrier Precautions (EBP). The resident was admitted with diagnoses including toxic encephalopathy, Parkinson’s disease, and gastrostomy status, and was documented as moderately cognitively impaired, dependent on staff for toileting and lower body dressing, and frequently incontinent of bowels. The physician’s orders and active care plan required staff to use EBP, including gowns and gloves, during high-contact care activities such as ADL care, toileting, changing briefs, and linen changes due to the presence of a feeding tube. Surveyor observations showed that a CNA repeatedly entered and exited the resident’s room, which had an EBP sign on the door, without wearing a gown while assisting with toileting, perineal care, dressing, and changing bed linens. The CNA confirmed she was providing these high-contact care activities, verified that the resident was on EBP, and acknowledged that she did not wear a gown and that there was no supply of PPE near the room. A clear trash bag in the room contained discarded products but no used gowns. Review of the facility’s EBP policy dated 12/3/25 stated that, at minimum, staff must wear gloves and gowns during high-contact care activities including ADL care, toileting, and showers, which was not followed in this instance.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident received a significant medication error, indicating a failure in the medication administration process. Specific details about the actions or inactions leading to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Immediately Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the failure to promptly inform all required parties when significant events impacting the resident occurred, as required by regulation.
Untimely Completion of Admission MDS Assessment
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) admission assessment within the required timeframe for one resident. Specifically, a resident admitted with a diagnosis of encephalopathy had an MDS admission assessment completed 15 days after the entry date, exceeding the regulatory requirement that the assessment be completed no later than 13 days after admission. The resident's admission date and the corresponding MDS documentation were reviewed, confirming the late completion. Interviews with facility staff revealed a lack of clear policy regarding the timing of MDS assessments. The MDS Coordinator stated she relied on the Resident Assessment Instrument (RAI) manual for guidance but acknowledged the assessment was not completed within the required period. The Assistant Director of Health Services was unfamiliar with the completion date requirements, and the Executive Director indicated that staff should refer to the RAI manual for timing but did not provide further direction.
Missed Quarterly MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure that a quarterly Minimum Data Set (MDS) assessment was completed for a resident as required. Record review showed that the resident was originally admitted in early 2021 and most recently readmitted in mid-2024. Examination of the resident's MDS 3.0 assessments revealed that a quarterly MDS was completed in January 2025 and an annual MDS in June 2025, but there was no evidence of any MDS assessments being completed between these dates. According to the MDS Coordinator, a quarterly assessment should have been completed around April 2025, but this was not done, and the coordinator was unable to provide a reason for the omission. The resident was not out of the facility during the time the assessment was due. Interviews with facility staff, including the MDS Coordinator, Assistant Director of Health Services, and Executive Director, confirmed that the responsibility for completing MDS assessments rested with the MDS Coordinator, and that all expected the assessments to be completed on time. Review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual confirmed that quarterly MDS assessments must be completed at least every 92 days following the previous OBRA assessment. The failure to complete the required quarterly MDS assessment resulted in a deficiency for the facility.
Failure to Label Tube Feeding Formula Bag
Penalty
Summary
A deficiency was identified when a tube feeding formula bag used for a resident with a history of cerebral palsy, dysphagia, and other significant medical conditions was found to be unlabeled during an early morning observation. The bag, which was actively infusing formula via a pump, lacked essential information such as the resident's name, room number, date and time the feeding was hung, the type or brand of formula, and the rate of infusion. The resident's care plan and physician orders specified the need for enteral feedings and water flushes, and the resident was dependent on staff for these interventions due to cognitive and physical impairments. Interviews with nursing staff revealed that the day shift LPN had transferred the formula from its original container to a disposable bag due to equipment incompatibility and typically used stickers to label the bags. However, the sticker was either not applied or had fallen off, and the LPN did not reinforce the label or write directly on the bag as she had done previously. The night shift LPN, upon removing the bag, confirmed it was unlabeled and could not identify the formula type. The Assistant Director of Health Services confirmed that facility policy required all tube feeding bags to be labeled with specific information, which was not followed in this instance.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Maintain Cleanliness of Tube Feeding Equipment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for a resident who required tube feeding due to cerebral palsy and dysphagia. The resident, who had moderate cognitive impairment and required substantial to maximal assistance with eating, was observed to have an IV pole used for enteral feedings that was visibly dirty on multiple occasions. Specifically, surveyors noted brown, sticky spots on the legs of the IV pole during several observations over the course of a week. Interviews with facility staff, including the Assistant Director of Health Services and the Executive Director, confirmed that the IV pole was dirty and should have been cleaned. It was also revealed that the facility did not have a cleaning schedule or policy for cleaning multi-use equipment, contributing to the ongoing issue with the unclean IV pole used for the resident's tube feeding.
Failure to Document Resident's Meal Intake
Penalty
Summary
The facility failed to ensure documentation was completed regarding a resident's meal/dietary intake. Medical record review for Resident #45 revealed an admission on 04/16/24 and a discharge on 04/18/24, with diagnoses including acute kidney failure, asthma, and cerebral infarction without deficits. The baseline plan of care and active physician's orders indicated the resident was on a regular diet, mechanical soft with thin liquids. However, there was no documentation in the electronic health record indicating the resident consumed any meals during the stay. The Director of Nursing confirmed the lack of documentation and stated that staff should be recording the percentage of food consumed at each meal. The facility policy requires staff to document meal intake and offer alternatives if food is not accepted.
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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) |
|---|---|---|---|---|
| Sanctuary Pointe Nursing & Rehabilitation Center | 0.7 mi | ★★★★★ | 0 | 0 |
| Veranda Gardens Nursing & Rehabilitation Center | 1.2 mi | ★★★★★ | 6 | 0 |
| Burlington House Rehab & Alzheimer's Care Center | 1.8 mi | ★★★★★ | 1 | 0 |
| Home At Taylor's Pointe | 2.4 mi | ★★★★★ | 0 | 0 |
| Alois Alzheimer's Care Center | 2.6 mi | ★★★★★ | 7 | 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.