Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Widows Home Of Dayton during CMS and state inspections, most recent first.
A resident with significant cardiac history and an ICD repeatedly screamed out and reported being shocked over the course of a day. An LPN assessed the resident, suspected a UTI, unplugged and checked the bed, took vital signs, and wrote a note in a provider binder but did not document in the medical record or notify a physician, and she was unaware the resident had an ICD. Later, an RN received report that the resident had been screaming all day about being shocked, confirmed the presence of a pacemaker/ICD, noted an irregular and elevated heart rhythm, attempted to reach the on-call provider without success, and awaited a return call without sending the resident out before shift change. On the next shift, another LPN responded when the resident again screamed in pain, documented that the resident reported ICD shocks for several hours, obtained low BP and elevated HR, honored the resident’s request to go to the ER, contacted the on-call provider, and called EMS. EMS and hospital records showed the resident had experienced numerous ICD shocks associated with serious arrhythmias and required emergency treatment and ICU admission, while facility policy required vigilant monitoring, timely assessment, documentation, and immediate physician notification for significant changes in condition.
The facility failed to ensure that a CNA providing personal care was properly certified with the State of Ohio. A staff member originally hired as a housekeeper completed an online NATCEP but never took the state certification exam, and there was no CNA license listed for this individual on the Ohio Nurse Aide Registry. Despite this, the staff member worked multiple 12-hour shifts providing direct care. The DON and HR later acknowledged they were unaware the state test had not been completed and that required follow-up on certification status did not occur, affecting all residents in the facility.
A resident with significant cardiac history and an ICD experienced an acute change in condition characterized by screaming, reports that someone or the bed was shocking him, and later clear complaints of repeated ICD shocks over several hours. An LPN assessed the resident, suspected a UTI, unplugged and checked the bed, obtained vital signs but did not document them, did not recognize the presence of an ICD, and did not call the provider, instead only placing a note in a provider binder. Hours later, an RN documented chest "shocking" complaints and attempted to contact the on-call provider without a response, and subsequently another LPN documented ongoing ICD shocks, abnormal vital signs, and the resident’s request to go to the ER, after which the provider agreed to hospital transfer. EMS and hospital records confirmed frequent ICD firings, A-fib with RVR, and the need for cardiology consultation, antiarrhythmic therapy, and ICU admission. The DON confirmed that staff failed to notify the provider and document the acute change in condition as required by the facility’s Change in Condition policy.
A resident with a history of stroke, COPD, severe CAD, prior CABG, and an ICD repeatedly screamed out in pain and reported being shocked throughout a day and evening shift, but an LPN who assessed the resident did not document the complaints, assessment, or vital signs in the medical record or notify a physician, instead only noting the issue in a provider binder. A subsequent RN and then an LPN received report that the resident had been screaming about being shocked, and when the symptoms recurred, the resident was assessed, EMS was called, and he was found to be in A-fib with RVR and transported to the hospital, where he reported repeated ICD firings and required cardiology consultation, amiodarone, and ICU admission. The DON confirmed that facility policy requires documentation of changes in condition and that the resident’s record lacked required entries for the earlier acute change in condition.
A resident admitted without pressure ulcers and assessed as low risk developed an unstageable, facility-acquired pressure ulcer after staff failed to complete required weekly skin assessments and did not identify the wound until it had advanced. Despite a care plan outlining preventive measures, documentation and assessment lapses led to the pressure ulcer's progression before it was properly addressed.
The facility did not ensure an RN was present for at least eight consecutive hours on one day, as confirmed by staffing records and staff interview, despite facility policy requiring daily RN coverage. This affected all residents in the facility.
Surveyors identified multiple failures in food safety and sanitation, including staff not wearing hair nets or gloves while handling food, improper labeling and storage of food items, evidence of pest infestation, and unsanitary kitchen conditions. These deficiencies were confirmed by staff and were not in compliance with facility policies, affecting all residents receiving dietary services.
Surveyors observed that two garbage cans in the kitchen food preparation area were left uncovered on multiple occasions, which was confirmed by a dietary staff member. Facility policy requires that garbage and refuse containers be covered when not in use.
Surveyors observed mouse droppings between the deep fryer and stove and on a rack below the steamer, as well as three cockroaches on the floor by the dry storage area. Dietary staff confirmed these findings. Pest control records indicated routine monthly treatments with no issues previously noted, despite the facility's policy requiring food service areas to be kept clean and free from pests.
Staff served meals in Styrofoam containers due to staffing shortages, and the main dining room was found with significant dust, debris, and a dead fly on the curtains. Multiple resident rooms and bathrooms were heavily soiled with black substances and unclean toilets, with staff confirming these conditions. Facility policy requires a clean, homelike environment, but these standards were not met in both dining and resident areas.
The facility did not consistently update care plans after changes in condition or complete required care conferences. For example, a resident with a new stage III pressure ulcer did not have this reflected in their care plan, and several residents with complex medical histories had no documented care conferences or incomplete documentation, despite facility policy requiring these actions.
Staff did not maintain safe and sanitary conditions in common areas, as evidenced by torn cove base, missing floor tiles creating trip hazards, a non-functioning ceiling light with a broken cover, and dusty ceiling vents with debris. These issues were confirmed by a CNA and the Maintenance Supervisor and had the potential to affect all residents, staff, and visitors.
A resident with multiple medical conditions expired in the facility, and the facility did not transfer the remaining balance of the resident's personal funds to the estate within the required thirty-day period, as confirmed by record review and staff interview.
A resident with multiple chronic conditions was found with several medications and supplements at her bedside, none of which had physician orders or documentation of administration. An LPN confirmed these items should have been secured in the medication cart, in accordance with facility policy requiring all drugs and biologicals to be stored in locked compartments.
A resident with multiple medical conditions did not receive her ordered meal and was instead given a peanut butter sandwich without being consulted, as kitchen staff failed to discuss alternative options when the requested item was unavailable. The resident confirmed this was a recurring issue, and facility policy requiring support of dietary choices was not followed.
A resident did not receive prescribed Percocet on multiple occasions due to unavailability, despite a physician's order. The resident, with a history of amputation and other medical conditions, was cognitively intact and required assistance with daily activities. Nurses' notes revealed communication issues with the pharmacy and lack of access to the Pyxis system, leading to missed doses. The facility's policy mandates timely administration of medications, which was not followed.
A resident with multiple medical conditions did not receive Insulin Glargine, Insulin Lispro, and Zoloft as ordered on several occasions, as confirmed by the MAR and a Regional Clinical Nurse. Despite the lack of documentation, the resident did not experience negative effects. The facility's policy requires medications to be administered safely and timely.
A resident at risk for pressure ulcers developed an unstageable ulcer on the right heel and a stage II ulcer on the left heel due to the facility's failure to implement preventive measures and conduct thorough skin assessments. The care plan lacked specific interventions for heel protection, and staff did not report early signs of skin breakdown. The ulcers were only identified during a wound assessment by a CNP, highlighting lapses in communication and documentation.
A resident with a surgical incision on the right knee showed signs of possible infection. Despite instructions from a CNP to notify the orthopedic surgeon, the facility staff only left a message and did not follow up. The resident was later transferred to the hospital for complications. The facility failed to adhere to its policy requiring prompt physician notification of significant changes.
The facility failed to follow a resident's enteral tube feeding orders, administering continuous feeding with incorrect flush amounts and not changing the enteral feed bag after 24 hours, as confirmed by the DON.
The facility failed to administer medications as ordered, resulting in a 9.67% medication error rate. A resident with multiple diagnoses had three medications omitted during a medication pass because the LPN could not locate them in the medication cart.
Failure to Respond Timely to Resident’s Repeated ICD Shock Complaints
Penalty
Summary
The deficiency involves the facility’s failure to provide timely, adequate, and necessary care, monitoring, and treatment following an acute change in condition for a resident with an implanted cardioverter defibrillator (ICD). The resident, who had a history of stroke, COPD, acute respiratory failure with hypoxia, coronary artery disease from ischemic cardiomyopathy, a low ejection fraction, prior coronary artery bypass grafting, and ICD placement, was alert and oriented per a recent MDS. On the day in question, the resident repeatedly complained of being shocked and screamed out in pain throughout the day. One LPN reported that the resident stated a man or the bed was shocking him; she suspected a UTI, unplugged and checked the bed, took vital signs, and wrote a note in a provider binder for follow-up the next day, but did not document the event in the medical record or notify a physician. She also stated she did not know the resident had an ICD. Later that evening, an RN received report that the resident had been screaming all day about being shocked. When the RN assessed the resident around 9:30 P.M., the resident reported being shocked by his pacemaker. The RN, who stated he was unaware of the pacemaker until the resident mentioned it, reviewed the record and confirmed the device, noted an irregular and elevated heart rhythm, and documented that the resident complained of a shocking feeling in his chest with heart rates of 64 and 69 bpm. The RN attempted to contact the on-call provider but received no answer and awaited a return call; he did not obtain further orders or send the resident to the hospital before the end of his shift. He reported to the oncoming LPN that the resident had complained of being shocked and instructed that the resident should be sent out if it occurred again. About an hour into the night shift, the oncoming LPN heard the resident screaming in pain, assessed him, and documented that the resident complained of ICD shocks that had been occurring for the last four hours. At that time, the resident’s vital signs included a BP of 94/59 mmHg, HR 92, RR 22, and O2 saturation of 96%, and the resident requested to go to the emergency room because the shocks were scaring him. The LPN contacted the on-call provider, who agreed to send the resident to the hospital, and EMS was called. EMS documented that the resident reported 12–15 ICD shocks in the prior three hours, with heart rates rising to 225 bpm and atrial fibrillation with rapid ventricular response. Hospital records and the medical director’s note later indicated the resident had been in ventricular tachycardia with repeated ICD defibrillations, hypokalemia, and more than 35 shocks per ICD report, requiring antiarrhythmic medications, IV drips, and ICU admission. The facility’s change in condition policy required vigilant monitoring, comprehensive assessment, documentation in the medical record, and immediate physician notification for significant changes, which were not consistently followed in this case.
Unlicensed CNA Allowed to Provide Resident Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure that employed CNAs were properly certified with the State of Ohio, as required by facility policy and state regulations. Personnel record review showed that CNA #13 was originally hired as a housekeeper and later completed an online Nurse Aide Competency Evaluation Program (NATCEP), but there was no evidence she had obtained state certification. Timecard review for February 2026 showed CNA #13 worked multiple 12-hour shifts providing care. Review of the Ohio Nurse Aide Registry confirmed there was no current or expired CNA license for CNA #13. The facility’s policy on required training and certification stated that nurse aides must have successfully completed a state-approved NATCEP and either be awaiting certification results or be enrolled in a state-approved NATCEP within the first four months of employment, with certification to be verified through the state registry. Interviews further confirmed that CNA #13 was not licensed and was nonetheless providing personal care to residents. The DON acknowledged that CNA #13 had completed an online CNA program but never took the state test for licensure and verified that she was not licensed as a CNA. CNA #13 herself confirmed she was not licensed, was providing personal care, and reported that her scheduled state test had been cancelled during a government shutdown, and that the DON and Human Resources were not aware she had not completed the state test. Human Resources staff confirmed CNA #13 was not licensed and stated they failed to follow up after her test was cancelled. The facility census at the time was 65 residents, and the failure to ensure proper CNA licensure had the ability to affect all residents.
Failure to Notify Provider of Acute Change in Condition Related to ICD Shocks
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician or non-physician provider when a resident experienced an acute change in condition. Resident #52, admitted with diagnoses including cerebral infarction, COPD, and acute respiratory failure with hypoxia, had intact cognition per a recent MDS with a BIMS score of 15. On 01/31/26, between 11:00 A.M. and 10:55 P.M., there was no documented evidence that the physician or on-call provider was contacted when the resident had an acute change in condition around 1:00 P.M. Later that evening at 10:56 P.M., an RN documented that the resident complained of a shocking feeling in his chest; assessment showed a pacemaker with heart rates of 64 and then 69 bpm, and the on-call provider was contacted but did not answer, with the nurse awaiting a return call. In the early hours of 02/01/26 at 12:55 A.M., an LPN documented that the resident complained his ICD had been shocking him for the last four hours, with vital signs including BP 94/59 mmHg, HR 92, RR 22, and O2 sat 96%. The resident requested transfer to the emergency room due to fear from the shocks, and the on-call provider then agreed to send him to the hospital; EMS later recorded elevated heart rates up to 225 and documented that the resident reported 12–15 ICD shocks in the prior three hours and was in A-fib with RVR. Hospital records showed the resident, with significant cardiac history including CAD, ischemic cardiomyopathy with EF 20–25%, prior CABG, and ICD placement, required cardiology consultation, initiation of amiodarone, and ICU admission. In an interview, the resident stated he had been shocked and initially was not sent out despite significant discomfort. An LPN who worked the 7:00 A.M. to 8:00 P.M. shift on 01/31/26 reported the resident was screaming and saying a man or the bed was shocking him; she suspected a UTI, unplugged and checked the bed, took vital signs but did not document them, did not know he had an ICD, and only placed a written note in the provider binder without calling the provider about the acute change. The DON confirmed staff should document and notify the provider for acute changes and verified the provider was not notified of the change in condition on 01/31/26, contrary to the facility’s Change in Condition policy requiring immediate physician notification for significant changes.
Failure to Document Resident’s Acute Change in Condition and Cardiac Symptoms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for a resident who experienced an acute change in condition. The resident, admitted with diagnoses including cerebral infarction, COPD, and acute respiratory failure with hypoxia, had intact cognition as shown by a BIMS score of 15. On the date in question, there was no nursing documentation between 11:00 A.M. and 10:55 P.M. regarding the resident’s complaints of being shocked and screaming in pain, despite multiple reports that these symptoms occurred throughout the day. According to interviews, a day-shift LPN reported that the resident was screaming and saying that a man or the bed was shocking him. Believing the resident might have a UTI because he “was not making any sense,” the LPN unplugged and checked the bed, took vital signs, and wrote a note in the provider’s binder for follow-up, but did not document the assessment or the resident’s complaints in the medical record and did not notify a physician. The LPN also stated she did not know the resident had an ICD. Later, an RN who relieved the day-shift nurse received report that the resident had been screaming all day about being shocked. When the resident again screamed out and reported being shocked by his pacemaker, the RN assessed him, noted an irregular and elevated heart rhythm, and attempted to contact the on-call provider, but the first related entry in the medical record was not made until 10:56 P.M. Subsequently, the night-shift LPN received report that the resident had been screaming in pain most of the day due to being shocked. About an hour into that shift, the resident again screamed out in pain, was assessed, and EMS was called. EMS documented that the resident complained of shocking chest pain and was in A-fib with RVR, and he was transported to the hospital. Hospital records showed the resident reported repeated ICD firings and had a significant cardiac history including CAD from ischemic cardiomyopathy, low ejection fraction, prior CABG, and ICD placement, and he required cardiology consultation, initiation of amiodarone, and ICU admission. The DON confirmed that staff are required by policy to document changes in condition in the medical record and verified that the resident’s record lacked documentation from the day-shift LPN regarding the acute change in condition.
Failure to Complete Timely Skin Assessments Resulting in Advanced Pressure Ulcer
Penalty
Summary
The facility failed to thoroughly assess and monitor the skin integrity of a resident who was admitted without pressure ulcers and assessed as low risk for their development. Despite having a care plan in place that included interventions such as regular repositioning, use of pressure-relieving devices, nutritional support, and weekly skin assessments by a licensed nurse, there were significant lapses in the execution and documentation of these interventions. Specifically, weekly skin assessments were not completed for three consecutive weeks, and shower sheets did not document any wounds or open areas during this period. A new skin issue was first identified as moisture-associated skin damage (MASD) with scabbing, but no detailed assessment or measurements were performed at that time. Subsequently, a wound nurse practitioner assessed the area and classified it as an unstageable, facility-acquired pressure ulcer with 100% slough tissue, requiring sharp debridement. The resident's care plan was updated to reflect the presence of the pressure ulcer, and dietary notes indicated an increased need for nutrition to promote wound healing. However, the pressure ulcer risk assessment continued to rate the resident as low risk, with no noted limitations in mobility. Interviews with facility staff confirmed the missed weekly skin assessments and the failure to identify the wound until it had reached an advanced stage. The facility's own wound management policy required weekly wound and skin assessments, and national guidelines emphasized the importance of comprehensive and ongoing skin assessments to detect early signs of pressure damage. The lack of timely and thorough skin assessments directly contributed to the development and progression of the resident's pressure ulcer.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was scheduled for at least eight consecutive hours daily, as required by both facility policy and regulatory standards. Review of staffing schedules for a specified period revealed that on one date, there was no RN present in the facility for the required duration. This was confirmed during an interview with the Clinical Director, who acknowledged the absence of an RN on that day. The facility's own policy mandates the presence of an RN for at least eight consecutive hours each day, seven days a week. The census at the time was 68 residents, all of whom had the potential to be affected by this lapse.
Widespread Food Safety and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to ensure that food was prepared, stored, and served in accordance with professional standards, resulting in multiple deficiencies observed during survey. Staff were observed not following required hygiene practices, such as a CNA assisting with food preparation without wearing a hair net and other staff handling ready-to-eat foods with bare hands instead of gloves. Additionally, clean plates were dried with a rag after being washed, and food preparation utensils, such as spatulas, were found to be burnt and blackened. Sanitation and food storage practices were also deficient. The kitchen and storage areas contained evidence of pest infestation, including mouse droppings and large insects. Food items in both coolers and freezers were found to be unlabeled, undated, unsealed, and in some cases, expired. There was also a foul odor and a puddle of reddish-brown liquid in the walk-in cooler, attributed to meat thawing, with staff unable to confirm how long the liquid had been present. Dry storage areas had food stored directly on the floor and opened items without proper labeling or dating. Physical conditions in the kitchen further contributed to the deficiencies, with open windows and damaged screens allowing potential pest entry, and oven hood vents caked with a fuzzy white substance. These observations were confirmed by staff interviews, and a review of facility policies indicated that the observed practices were not in compliance with established food safety and sanitation requirements. The facility census at the time was 68 residents, with one resident identified as not receiving food from the kitchen.
Uncovered Garbage Cans in Kitchen Food Preparation Area
Penalty
Summary
Staff failed to ensure that garbage cans in the kitchen food preparation area were covered, as required by facility policy. On two separate observations, surveyors noted that two garbage cans in the food preparation area were left uncovered. This was confirmed in an interview with a dietary staff member, who acknowledged that the garbage cans were not covered. Review of the facility's policy indicated that garbage and refuse containers should be covered when not in use. The facility census at the time was 68 residents. No information was provided regarding any specific residents' medical history or condition at the time of the deficiency.
Failure to Maintain Effective Pest Control in Kitchen
Penalty
Summary
The facility failed to maintain effective pest control in the kitchen area, as evidenced by direct observations and staff interviews. On the morning of 05/18/25, several black specs, later confirmed by dietary staff as mouse droppings, were found on the floor between the deep fryer and stove, as well as on a rack below the steamer. Additionally, three cockroaches were observed on the floor by the dry storage area, which was also confirmed by dietary staff. Review of pest control documentation showed that routine monthly services had been performed in the preceding months, with no issues noted during those visits. The facility's policy requires all food service areas to be kept clean, sanitary, and protected from rodents and insects, but these conditions were not met at the time of the survey.
Failure to Maintain Clean and Homelike Environment in Dining and Resident Areas
Penalty
Summary
The facility failed to provide a clean and homelike environment for its residents, as evidenced by multiple observations and staff interviews. During breakfast, residents were served meals in Styrofoam containers due to staff shortages, as confirmed by dietary staff. The main dining room was found to have significant cleanliness issues, including a large ceiling vent, curtains, curtain rods, and sprinkler heads all covered in a thick, gray, fuzzy material, with some of it visibly blowing through the air. A dead house fly was observed stuck to the curtains, and a long string of the gray material was hanging from a ceiling tile. The dining room floor was also heavily soiled with food debris and liquid stains, and staff confirmed that the area had not been cleaned due to short staffing. Additionally, three resident rooms were observed to be heavily soiled, with floors and walls covered in an unknown black substance, and bathrooms containing heavily soiled floors and toilets with black rings. These conditions were confirmed by a CNA during the observations. The facility's own policy requires a safe, clean, and homelike environment, but these standards were not met in the dining area or resident rooms, affecting both the overall environment and the daily living experience of the residents.
Failure to Update Care Plans and Complete Required Care Conferences
Penalty
Summary
The facility failed to ensure that care plans were updated in a timely manner following changes in residents' conditions and did not consistently complete or document required care conferences. For one resident with diabetes, mood disturbance, dementia, and a pressure ulcer, the care plan was not updated to reflect the development of a stage III pressure ulcer, despite a physician's order for treatment and confirmation by nursing staff. The facility's policy required care plans to be revised as needed, but this was not followed. Multiple residents did not have evidence of care conferences being held or documented as required. One resident with congestive heart failure, diabetes, COPD, depression, and schizoaffective disorder had no documented care conferences, and the care plan was not updated to include a new diagnosis of schizoaffective disorder. Another resident with a fracture, PTSD, depression, and glaucoma had no care conference documented for over a year. Additional residents with various diagnoses, including cognitive impairment and physical disabilities, either had no care conferences documented or had incomplete documentation, such as missing signatures or dates. Interviews with residents and clinical staff confirmed the lack of care conferences and incomplete or outdated care plans. Facility policy required care plan discussions with residents and/or their representatives at regular intervals and after significant changes, with proper documentation and signatures, but these procedures were not consistently followed for several residents reviewed.
Failure to Maintain Safe and Sanitary Common Areas
Penalty
Summary
Facility staff failed to maintain a safe, functional, and sanitary environment in the common areas, as evidenced by several direct observations and staff interviews. On one occasion, the cove base at the entrance to the rehab hallway was found to be ripped and torn, with multiple missing floor tiles, which a CNA confirmed as being in disrepair and presenting a trip hazard to residents, staff, and visitors. Additionally, the ceiling light at the entrance to the rehab unit was not working, and its cover was broken, as confirmed by the Maintenance Supervisor. Further observation revealed that ceiling vents on the Sea Side Lane unit were dusty with debris hanging down, which was also acknowledged by the Maintenance Supervisor. These deficiencies had the potential to affect all 68 residents residing in the facility.
Failure to Timely Transfer Deceased Resident's Personal Funds
Penalty
Summary
The facility failed to transfer the personal funds of a deceased resident to the resident's estate within the required thirty-day period. Medical record review showed that the resident, who had diagnoses including anemia, atrial fibrillation, hypertension, dementia, and depression, expired in the facility. Review of the resident fund account records indicated that the facility sent a check for the remaining balance of $245.51 to the estate, but this was not completed within the mandated timeframe. An interview with the Business Office Manager confirmed that the refund was not processed within thirty days as required by facility policy and regulations.
Medications Improperly Stored at Bedside Without Orders or Documentation
Penalty
Summary
A deficiency was identified when a resident was found to have multiple medications and supplements, including cranberry supplement, probiotic tablets, Refresh Tears eye drops, Replenish eye drops, Ketorolac eye drops, multivitamin capsules, and Tums tablets, stored in bottles on her bedside table. Review of the resident's medical record and Medication Administration Record (MAR) revealed there were no physician's orders or documentation for administration of these medications and supplements. The resident was cognitively intact and required staff assistance with activities of daily living, with diagnoses including polyneuropathy, congestive heart failure, hypertension, and acute respiratory failure with hypoxia. Observation and interview with an LPN confirmed that these medications should not have been at the resident's bedside and should have been locked in the medication cart. The facility's policy required all medications to be stored in locked compartments, medication carts, cabinets, drawers, or refrigerators, and to be housed according to manufacturer recommendations to ensure security and proper storage conditions. The failure to store medications securely and the presence of medications without physician orders or documentation constituted a violation of the facility's medication storage policy.
Resident Meal Preferences Not Honored
Penalty
Summary
A deficiency occurred when a cognitively intact resident with multiple diagnoses, including a left humerus fracture, PTSD, depression, and glaucoma, did not receive her ordered meal. The resident had ordered a hot dog, mashed potatoes, and fruit for lunch, but instead received mashed potatoes, fruit, and a peanut butter sandwich. The resident confirmed that she often did not receive what was listed on the menu and would instead be given a peanut butter and jelly sandwich. Observation during lunch service confirmed the resident received a peanut butter sandwich instead of the hot dog she had ordered. The Director of Nutritional Services verified that the kitchen did not have hot dogs available and that staff did not discuss alternative menu options with the resident. Instead, staff assumed the resident would want a peanut butter sandwich without confirming her preference. Facility policy stated that residents' rights to make personal dietary choices would be supported, but this was not followed in this instance.
Medication Availability Deficiency
Penalty
Summary
The facility failed to ensure that a medication, Percocet, was available for administration as ordered for a resident. The resident, who was admitted with medical diagnoses including acquired absence of left below knee amputation, peripheral vascular disease, diabetes mellitus, and hypertension, was cognitively intact and required varying levels of staff assistance for daily activities. A physician order dated 09/12/24 prescribed Percocet 5-325 mg to be given every four hours for pain. However, the Medication Administration Record (MAR) showed that the resident did not receive the medication on several occasions, specifically on 10/12/24, 10/13/24, 10/18/24, 10/28/24, and 12/04/24. Nurses' notes indicated communication issues with the pharmacy and lack of access to the Pyxis system, which contributed to the medication not being available. On 10/18/24, a nurse noted that the pharmacy promised delivery of the medication in the evening, but by 10/19/24, the resident was still out of Percocet. The nurse and the on-call supervisor both lacked access to the Pyxis system to obtain the medication. On 12/04/24, another note stated that the medication was not available in the medication cart and had to be reordered. Interviews with the resident and the Regional Clinical Nurse confirmed the lack of documentation for the administration of Percocet on the specified dates. The facility's policy required medications to be administered safely and timely, as prescribed, which was not adhered to in this case.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, affecting one resident out of the three reviewed for medication administration. The resident, who was cognitively intact and required supervision with certain activities, had medical diagnoses including myocardial infarction, cerebral infarctions, diabetes mellitus with neuropathy, spinal stenosis, and congestive heart failure. The resident had physician orders for Insulin Glargine, Insulin Lispro, and Zoloft, but the November 2024 Medication Administration Record (MAR) lacked documentation to support that these medications were administered as ordered on multiple dates. An interview with the Regional Clinical Nurse confirmed the absence of documentation for the administration of the resident's medications as ordered in November 2024. Despite the lack of documentation, it was confirmed that the resident did not experience any negative effects from the medications not being administered as ordered. The facility's policy on administering medications stated that medications should be administered in a safe and timely manner, as prescribed, and in accordance with the orders, including any required time frame. This deficiency was investigated under a specific complaint number.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to adequately assess and implement preventive measures for pressure ulcers, resulting in actual harm to a resident. The resident was admitted without pressure sores but was at risk for developing them due to impaired mobility and incontinence. Despite being identified as at risk, the care plan did not include specific interventions for heel protection, such as offloading or using heel protectors. The facility's Treatment Administration Record (TAR) lacked orders for heel protection, and the resident's heels were not offloaded, leading to the development of an unstageable pressure ulcer on the right heel and a stage II ulcer on the left heel. The facility's staff did not conduct thorough skin assessments as required. Although the resident's care plan included daily skin assessments and weekly checks by a licensed nurse, the only documented weekly skin assessment indicated no pressure ulcers. However, an occupational therapist noted reddened areas on the resident's heels, which were not reported to the nursing staff. The pressure ulcers were only identified during a wound assessment by a Certified Nurse Practitioner (CNP) several days later, by which time the ulcers had progressed significantly. Interviews with facility staff confirmed lapses in communication and documentation. The CNP reported the pressure ulcers to the Director of Nursing (DON) and provided treatment orders, but the facility's nursing staff failed to identify the ulcers in a timely manner. The DON acknowledged that the facility's policy required weekly skin assessments and that the resident's care plan lacked necessary interventions for heel protection. The facility's policy emphasized the prevention of avoidable pressure injuries, but the lack of adherence to these protocols contributed to the resident's harm.
Failure to Communicate Significant Change in Resident's Condition
Penalty
Summary
The facility failed to ensure proper communication between nursing staff and resident physicians regarding significant changes in a resident's condition. This deficiency affected a resident who was admitted with multiple diagnoses, including a periprosthetic fracture and a history of falling. The resident had undergone surgical revision of a right total knee replacement and was noted to have a surgical incision on the right knee. Initially, the incision was healing well, but later showed signs of possible infection. Despite instructions from a Certified Nurse Practitioner (CNP) to notify the orthopedic surgeon about the changes in the wound, the facility staff only left a message with the surgeon's office and did not follow up further. The resident was scheduled for a follow-up appointment with the orthopedic surgeon, but due to the lack of additional communication from the facility, the resident was not seen earlier than the scheduled date. Upon attending the appointment, the surgeon transferred the resident to the hospital for evaluation of complications related to the knee surgery. The facility's policy required prompt notification of physicians when significant changes occurred, but this was not adhered to, resulting in a deficiency noted during the investigation.
Failure to Follow Enteral Tube Feeding Orders
Penalty
Summary
The facility failed to ensure that a resident's enteral tube feeding orders were implemented as prescribed. Resident #82, who has diagnoses including chronic obstructive pulmonary disease, lupus, gastrostomy tube, and West Nile virus, had physician orders for Jevity 1.5 calories at 70 milliliters per hour for 22 hours and a 50 ml free water flush for the same duration. However, the Licensed Practical Nurse (LPN) responsible for the resident on 04/30/24 did not follow these orders, instead administering the enteral nutrition continuously with a 250 ml flush every four hours. This discrepancy was confirmed by the Director of Nursing (DON) during an interview and observation on 05/01/24, where it was also noted that the enteral feed bag had not been changed after 24 hours as required by the facility's policy. The DON verified that the enteral nutrition and fluid flush order for Resident #82 was not followed as ordered and that the enteral bag was still in use beyond the 24-hour limit. The facility's policy on the care and treatment of feeding tubes, dated 05/01/24, mandates that feeding tubes be utilized according to physician orders. This deficiency was identified during an investigation under Complaint Number OH00152784.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were administered as physician ordered, resulting in a 9.67% medication error rate. This affected one resident observed for medication administration pass. The resident, who has diagnoses including end-stage renal disease, chronic obstructive pulmonary disease, and stroke, had physician orders for ProRenal + D Oral Tablet, Acidophilus Capsule, and Olopatadine Ophthalmic Solution. During a medication pass observation, an LPN was unable to locate these medications in the medication cart, leading to their omission. The LPN verified that the medications were unavailable and were being omitted.
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Illustrative
What surveyors actually found near you
We read the 580 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Dayton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Beavercreek Health And Rehab | 1.9 mi | ★★★★★ | 7 | 0 |
| Sanctuary At Wilmington Place | 2 mi | ★★★★★ | 1 | 0 |
| Gem City Healthcare And Rehabilitation Center | 2.4 mi | ★★★★★ | 9 | 0 |
| Dunbar Health & Rehab Center | 2.7 mi | ★★★★★ | 0 | 0 |
| Grafton Oaks Nursing Center | 2.7 mi | ★★★★★ | 16 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.