Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Twin Towers during CMS and state inspections, most recent first.
Failure to Identify and Manage Heel Pressure Injuries: Two residents who were admitted without pressure ulcers and were assessed as high risk developed serious right heel pressure injuries. One resident’s heel was not consistently offloaded and the wound was not identified until it had progressed to a DTI/unstageable injury; the other resident’s heel was documented as a ruptured blister that progressed to a stage III pressure ulcer, with missed off-loading and treatment documentation in the TAR and incomplete skin surveillance.
Failure to notify responsible parties of changes in condition affected two residents, including a resident with ESRD, COPD, hypothyroidism, and moderately impaired cognition who experienced significant weight loss from 118.6 lb. to 93 lb. The resident's daughter said she knew the resident was not eating but had not been told about the weight loss, and the RD verified there was no documentation that the responsible party was notified. The DON stated nursing notifications would be documented if completed, and the facility policy required prompt notification of the resident and representative when health status changed.
Inadequate Monitoring of Significant Weight Changes: The facility failed to verify significant wt changes for two residents with repeated large fluctuations in documented weights. One resident with Parkinsonism, cognitive communication deficit, and bipolar disorder had multiple significant wt loss/gain events, and the RD confirmed re-wts were not obtained to validate the changes. Another resident with Alzheimer's dementia, DM2, and HTN had several major wt changes, including a delayed re-wt after a significant loss. The RD and DON stated significant wt changes were expected to trigger prompt re-wts, but this did not occur consistently.
The facility failed to ensure proper food safety practices, affecting 72 residents. A staff member with a beard was observed preparing food without a beard cover, contrary to facility policy. Additionally, frozen foods were improperly stored, with items left open to air in the freezer. The Dietary Manager confirmed these practices were against the facility's policies.
The facility failed to conduct fit testing for respirators required for staff working with COVID-19 positive residents. An STNA was observed exiting a COVID-19 positive resident's room without the proper N95 respirator, and interviews revealed that other staff, including LPNs, had not been fit tested. The facility's policy requires fit testing upon hire and annually, but no records were available due to staff turnover and administrative changes.
A facility failed to notify a physician about a resident's bleeding during urinary catheter changes over several months. Despite the resident's history of prostate issues and moderate cognitive impairment, the LPN did not inform the physician of the bleeding incidents, which were documented multiple times. The facility's policy mandates notifying the physician of such health status changes, but this was not adhered to.
A resident with moderate cognitive impairment and a history of urinary issues had a physician's order for a specific catheter size, which was not followed by an LPN during a catheter change. The LPN used a larger balloon size due to unavailability of the correct size, causing the resident discomfort and hematuria. The DON and Administrator expected adherence to physician orders, and the physician was not informed of the deviation.
A resident with a history of urinary issues received inappropriate catheter care due to a nurse using a larger balloon size than ordered, causing discomfort and hematuria. The facility lacked regular nursing competencies and relied on computer-based education, contributing to the deficiency.
The facility failed to implement pharmacy recommendations for two residents regarding unnecessary medications. One resident continued to receive antipsychotic and antidepressant medications without a stop date, despite the physician agreeing to discontinue them. Another resident was given an antipsychotic without an allowable diagnosis, and the pharmacist's request for a diagnosis went unanswered. Staff interviews revealed that pharmacy recommendations were not consistently followed.
A survey revealed a medication error rate of 16.13% in an LTC facility, involving two residents. Errors included administering incorrect supplements and medications, such as Azo-Cranberry instead of cranberry concentrate and ferrous sulfate instead of ferrous gluconate. The RN acknowledged the errors, and the pharmacist confirmed the discrepancies. The facility's policy on medication administration was not followed.
Failure to Identify and Manage Heel Pressure Injuries
Penalty
Summary
The facility failed to thoroughly assess residents’ skin and failed to identify pressure injuries until they had advanced. Resident #66 was admitted without pressure ulcers, was assessed as high risk for pressure injury development, and had diagnoses including Alzheimer’s disease, difficulty walking, muscle weakness, and fracture around an internal prosthetic joint. The care plan and physician orders called for weekly skin checks and for the heels and ankles to be offloaded with pillows every shift, but the TAR showed missed documentation of heel offloading on multiple dates. The weekly skin assessment on 02/13/26 documented no skin impairment, and there was no progress note identifying a right heel wound until 02/16/26, when RN #350 noted a black area on the right heel that appeared pressure related and painful to touch. Resident #66’s right heel progressed from a black area to a DTI and then to an unstageable pressure injury. WCNP #900 later documented the wound as an in-house acquired unstageable pressure ulcer of the right heel, and subsequent assessments described increasing wound size and necrotic tissue. On 02/25/26, observation showed the resident’s right foot had a padded boot in place, the left heel was not offloaded, and neither heel was being floated. CNA #505 confirmed the heels were not being floated and then placed foam wedges under the calves. RN #350 stated the wound was first reported on 02/16/26, and the DON verified the wound was discovered that day and that ordered treatment was not initiated until 02/18/26. Resident #76 was admitted without pressure ulcers, had diagnoses including CHF, atrial fibrillation history, CAD, and COPD, and was assessed as high risk for pressure injury development. The baseline plan of care included turning and repositioning every two hours, elevating the heels off the bed, and applying off-loading boots. On 02/15/26, RN #615 documented a ruptured blister to the right lateral heel, measured it, cleansed it, applied triple antibiotic ointment, and covered it with a dry dressing while awaiting WCNP #900’s response. The resident’s TAR showed multiple missed treatments and missed off-loading boot applications after orders were received, and shower documentation was incomplete for the admission period. WCNP #900 later assessed Resident #76’s right heel as a stage III pressure ulcer and documented that staff had reported it as present on admission, although WCNP #900 also stated she had only been told about groin redness on admission and had not been told about a heel blister. RN #615 stated she had seen what looked like a ruptured blister and notified WCNP #900. The DON verified the resident went from having no pressure ulcer on admission to developing a stage III right heel pressure ulcer, and the record also showed later documentation describing the wound as unstageable with eschar. The facility policy and NPIAP guidance in the report emphasized comprehensive skin assessment, including attention to heels and other bony prominences, and ongoing skin assessment to detect early signs of pressure damage.
Failure to Notify Responsible Parties of Significant Weight Loss
Penalty
Summary
The facility failed to ensure resident responsible parties were notified of changes in condition for two residents, including significant weight loss. Resident #08 was admitted with diagnoses of ESRD, dependence on renal dialysis, COPD, and hypothyroidism, and the comprehensive MDS showed moderately impaired cognition with supervision needed for eating and partial/moderate assistance with ADLs. The medical record documented a progressive decline in weight from 118.6 lb. to 93 lb. over the review period, but there was no documented evidence that the resident's responsible party was notified of the weight loss. During interview, the resident's daughter stated she knew her mother was not eating but had not been told about the weight loss and believed the last weight she knew was 115 lb. The RD stated she relied on nursing to notify responsible parties when she had new orders and had no process for notifying them of weight loss, and she verified there was no documentation that the responsible party had been notified of the significant weight loss. The DON stated that notifications made by nursing staff would be documented in the medical record if completed. The facility policy required prompt notification of the resident and resident's representative when there was a change in health status, including illness, injury, or death, and required documentation of the notification and any intervention taken.
Inadequate Monitoring of Significant Weight Changes
Penalty
Summary
The facility failed to adequately monitor resident weights to ensure the accuracy of documented weight loss and weight gain for two residents reviewed for nutrition. The deficiency was identified through record review and staff interviews, and it involved residents with significant fluctuations in documented weights that were not promptly re-weighed to confirm whether the changes were accurate. Resident #10 had diagnoses including Parkinsonism, cognitive communication deficit, and bipolar disorder, and was ordered a regular diet with regular consistency. The record showed a weight of 195 lbs. on 10/08/25 and 172.8 lbs. on 11/21/25, followed by 204.4 lbs. on 12/19/25 and 210.8 lbs. on 02/01/26, with 187.2 lbs. on 02/08/26. These documented changes reflected significant weight loss and gain over short periods. The nutrition progress notes documented that the physician was notified of the weight changes, but there was no recommendation for a re-weight. During interview, the RD verified that significant weight changes should trigger a re-weight, and the RD confirmed that re-weights were not obtained to validate the documented changes. The DON stated her expectation was that a resident with a significant weight gain or loss should have a re-weight within two days. Resident #12 had diagnoses including Alzheimer's dementia, malignant neoplasm of the right breast, diabetes mellitus type II, and hypertension. The admission and annual care plans identified the resident as at risk for altered nutrition and included interventions such as supplements, monitoring intake, and evaluating weight records. The record showed multiple large weight changes, including 170 lbs. to 182.8 lbs., 182.8 lbs. to 192.2 lbs., 192.2 lbs. to 180 lbs., 180 lbs. to 140.2 lbs., and 140.2 lbs. to 177.1 lbs., with several of these changes meeting criteria for significant gain or loss. Nutrition notes documented that the physician was notified of weight changes, but there was no recommendation for a re-weight in some instances, and a re-weight requested for the 140.2 lbs. weight was not obtained until 01/21/26. The RD verified the resident was on a monthly weight schedule and that significant weight changes were to be re-weighed within one week, while the DON stated the expectation was within two days. The facility policy stated residents are to be weighed at least monthly and reweighed if a significant weight loss is noted or to confirm accuracy of weight.
Food Safety Violations in Kitchen
Penalty
Summary
The facility failed to ensure proper food safety practices in the kitchen, which had the potential to affect all 72 residents receiving meals. During an observation, a staff member with a full beard was seen preparing food without a beard cover. The staff member admitted to not knowing the requirement for wearing a beard cover, and the Dietary Manager confirmed that a beard cover should have been worn. The facility's policy, revised in January 2024, mandates that all facial hair be restrained with a beard net or restraint when working with food. Additionally, the facility did not properly store frozen foods. During an observation, a hamburger patty and a box of chicken tenders were found left open to air in the freezer. The Dietary Manager acknowledged that the food should have been sealed to prevent contamination. The facility's policy on food storage, also revised in January 2024, requires that unused portions and open packages be covered, labeled, and dated, and that food in frozen storage be wrapped tightly to prevent cross-contamination.
Failure to Conduct Respirator Fit Testing for COVID-19 Protection
Penalty
Summary
The facility failed to ensure that staff were fit tested for respirators required for respiratory protection when working with COVID-19 positive residents. This deficiency was observed when a State tested Nurse Aide (STNA) was seen exiting a COVID-19 positive resident's room wearing a surgical mask and gloves, instead of the required N95 respirator. The STNA admitted to not being fit tested for a respirator, despite wearing an N95 mask over a surgical mask when entering the room. Interviews with other staff members, including Licensed Practical Nurses (LPNs), revealed that they also had not been fit tested for respirators. The facility's Administrator and Director of Nursing (DON) acknowledged the lack of fit testing records, attributing it to staff turnover and changes in administration. The facility's policy on respiratory protection, which mandates fit testing upon hire and annually, was not adhered to, as no records could be provided. The policy also requires maintaining fit testing records for at least six years, which the facility failed to do, potentially affecting all 72 residents in the facility.
Failure to Notify Physician of Bleeding During Catheter Changes
Penalty
Summary
The facility failed to notify the physician regarding bleeding incidents during indwelling urinary catheter changes for a resident with a history of benign prostatic hyperplasia and obstructive and reflux uropathy. The resident, who had moderate cognitive impairment, experienced multiple instances of bleeding during catheter changes over several months. Despite the presence of blood in the urine and small blood clots during these procedures, there was no documentation indicating that the physician was informed of these occurrences. The Licensed Practical Nurse (LPN) responsible for changing the resident's catheter regularly acknowledged that the resident bled during these changes due to prostate issues but did not notify the physician. The physician confirmed that they were unaware of the bleeding incidents. The facility's policy requires notifying the resident, their physician, and a representative of any changes in health status, but this protocol was not followed in this case.
Failure to Follow Physician Orders for Catheter Care
Penalty
Summary
The facility failed to ensure staff followed physician orders for indwelling urinary catheter care for a resident with a history of benign prostatic hyperplasia and obstructive uropathy. The resident, who had moderate cognitive impairment, had a physician's order for a #18 French size catheter with a 10 mL balloon to be changed monthly and as needed. However, during a catheter change, an LPN used a #18 Fr catheter with a 30 mL balloon instead, citing the unavailability of the correct size. This deviation from the physician's order resulted in the resident experiencing discomfort and hematuria during the procedure. The Director of Nursing and the Administrator both expressed that the expectation was for nurses to follow physician orders exactly as written. The DON noted that there was a stock supply of items on site that should have been used, and the LPN could have contacted the physician to delay the catheter change until the correct size was available. The physician was not informed of the use of a larger catheter balloon or the bleeding that occurred, and he emphasized that catheter sizes should not be changed for staff convenience. The facility's catheter care policy indicated that residents with indwelling catheters should receive care to maintain hygiene and prevent complications such as urinary tract infections.
Inadequate Nursing Competency in Catheter Care
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies to provide appropriate care for a resident with an indwelling urinary catheter. Resident #49, who had a medical history of benign prostatic hyperplasia and obstructive uropathy, was admitted with an indwelling urinary catheter. The physician's order specified the use of a #18 French size catheter with a 10 mL balloon. However, during a catheter change, LPN #1 used a #18 French size catheter with a 30 mL balloon, which was not in accordance with the physician's order. This resulted in the resident experiencing discomfort and hematuria during the procedure. The Director of Nursing (DON) acknowledged that the facility did not conduct regular nursing competencies or in-services on indwelling urinary catheter care. The DON also confirmed that there was no policy for staff competencies, and the facility relied mostly on computer-based education. The lack of proper training and adherence to physician orders led to the inappropriate catheter care provided to Resident #49, highlighting a deficiency in ensuring nursing staff had the appropriate skills and competencies.
Failure to Implement Pharmacy Recommendations for Unnecessary Medications
Penalty
Summary
The facility failed to implement pharmacy recommendations for two residents regarding unnecessary medications. Resident #58, who was admitted with a history of Alzheimer's disease and dementia, was receiving antipsychotic and antidepressant medications. The pharmacist recommended discontinuing melatonin and olanzapine, but the physician's orders did not reflect a stop date for these medications. Despite the physician agreeing with the recommendation, the medications continued without documented psychiatric notes to justify their use. Resident #72, admitted with Alzheimer's disease, depression, and cognitive communication deficit, was also receiving antipsychotic and antidepressant medications. The pharmacist noted that the resident was receiving an antipsychotic without an allowable diagnosis and requested a diagnosis from the physician. However, there was no response to this request, and the antipsychotic medication continued to be administered for depression, which is not an approved singular treatment. Interviews with facility staff, including the Director of Nursing and the Assistant Director of Nursing, revealed that while pharmacy recommendations were communicated to physicians, the expectation for these recommendations to be followed was not met. The pharmacist confirmed that he performed drug regimen reviews and requested necessary diagnoses, but did not receive responses, leading to continued medication administration without appropriate justification.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 16.13% during a survey. This was identified through observations, staff interviews, medical record reviews, and facility policy reviews. The errors involved two residents, one with chronic kidney disease and urinary tract infections, and another with heart failure, hypertension, and mild cognitive impairment. The errors were observed during medication administration by a registered nurse. For the first resident, the nurse administered Azo-Cranberry instead of the prescribed cranberry concentrate 500 mg. The Azo-Cranberry contained additional ingredients not present in the prescribed supplement. The nurse acknowledged the error during an interview, and the pharmacist confirmed that the two products were not equivalent, highlighting the need for clarification before administration. For the second resident, the nurse administered incorrect medications, including calcium with vitamin D3, ferrous sulfate instead of ferrous gluconate, non-extended release vitamin C, and a multivitamin without the specified B complex. The nurse admitted to the errors, citing confusion with the electronic medication administration record. The pharmacist confirmed these as medication errors, noting differences in medication effects and types. The facility's policy emphasized the importance of following the five rights of medication administration, which were not adhered to in these instances.
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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) |
|---|---|---|---|---|
| Ohio Living Llanfair | 0.7 mi | ★★★★★ | 4 | 0 |
| Mt Airy Gardens Rehabilitation And Nursing Center | 1.6 mi | ★★★★★ | 2 | 0 |
| Lakeridge Villa Health Care Center | 2.3 mi | ★★★★★ | 0 | 0 |
| Clovernook Health Care And Rehabilitation Center | 2.4 mi | ★★★★★ | 27 | 0 |
| Scarlet Oaks Nursing And Rehabilitation Center | 2.4 mi | ★★★★★ | 0 | 0 |
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