Below average — CMS composite of the measures below.
The next survey window likely opens around March 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 Woods Edge Rehab And Nursing during CMS and state inspections, most recent first.
Unsanitary food storage and handling practices were observed in the dietary area and on resident units. A DM found debris and scum in deep freezers, unlabeled and undated food and drinks in multiple refrigerators and freezers, a freezer without a thermometer, no soap at the hand hygiene sink, and contaminated items stored in a box of hair nets. The DM also handled pancakes with gloved hands after touching a ladle used for batter. Resident refrigerator/freezers had ice buildup, spills, debris, and one refrigerator measured 50 degrees F; a soda can was also stored on top of ice in a resident cooler.
The facility failed to properly label and store medications for multiple residents. An LPN observed opened insulin that had not been dated, including one insulin that remained in the cart after it had been discontinued. Surveyors also found expired multivitamin/mineral tablets and guaifenesin liquid in the medication storage room, and the DON confirmed the expired medications should have been discarded.
A resident with hemiplegia, moderate cognitive impairment, and a documented moderate fall risk had a care plan requiring two staff to assist with hygiene and dressing. During incontinence care and a bed bath, a CNA provided care alone, rolled the resident toward the wall, then turned away to clean the bed and obtain linens. While the CNA’s back was turned, the resident slid from the bed to the floor. An RN responded to the CNA’s call for help and assisted in returning the resident to bed with a Hoyer lift. The facility’s investigation, confirmed by the DON and RN, found that the resident required two-person assistance and that the CNA’s failure to follow the care plan led to the fall.
A resident with chronic kidney disease, cardiomegaly, PVD, and schizoaffective disorder was moderately cognitively impaired and dependent on staff for ADLs. Although the care plan directed staff to encourage call light use, the call light was observed hanging on the wall out of the resident’s reach while she was in bed, and both the resident and a CNA confirmed it was not reachable.
Dirty Air Conditioning Unit in Resident Room A resident’s wall AC unit next to the bed was observed coated with a black substance. The resident, who was cognitively intact and required supervision with ADLs, said he was concerned the substance could affect his health. A CNA confirmed the unit was coated and should be kept clean; facility policy required resident-area surfaces to be kept clean when visibly contaminated or soiled.
An LPN handled a resident’s medications with a bare hand, another LPN did not wash or sanitize hands before giving medications to a resident, and an LPN did not sanitize hands before returning to administer additional pain medication to the same resident. The facility policy required handwashing as the first step in medication administration and before moving to the next resident.
Failure to Offer Pneumococcal and Influenza Vaccines: The facility did not ensure that residents were offered pneumococcal vaccination upon admission and annually. One resident received a single pneumonia vaccine but was not offered additional doses, while two other residents were not offered the pneumonia vaccine on admission; one of those residents was also not offered the influenza vaccine. The DON confirmed the omissions, and the facility policy stated that all residents would be offered pneumonia vaccines.
Failure to Offer and Document COVID-19 Vaccination: The facility failed to offer the COVID-19 vaccine to two residents upon admission and annually, and vaccination status was not properly documented for the residents reviewed. One resident had anoxic brain damage, HTN, and chronic diastolic HF, and another had COPD, MDD, and DM. The DON confirmed both residents were not offered the vaccine upon admission, despite the facility's COVID-19 Protocols calling for resident education, vaccine offering, and documentation in the medical record.
The facility failed to thoroughly investigate, document, and assess falls for two residents with cognitive impairments and multiple diagnoses. In both cases, required post-fall evaluations and immediate interventions were not completed, and care plan interventions such as accessible call lights and non-skid strips were not maintained. The DON and an LPN confirmed lapses in documentation and adherence to facility protocols.
Staff failed to follow infection control protocols during wound care for a resident with a stage IV pressure ulcer under Enhanced Barrier Precautions. An LPN exited and re-entered the room wearing the same gown and gloves, and changed gloves multiple times without performing hand hygiene, contrary to facility policy. The DON confirmed these actions did not meet required infection control standards.
A resident with severe cognitive impairment and a history of exit-seeking behaviors made explicit threats to jump out a window, which were reported to staff including an LPN. Despite these warnings, the LPN did not assess or supervise the resident, and other staff either dismissed or failed to escalate the threats. The resident subsequently broke a second-story window and jumped out, sustaining a serious injury.
Staff failed to follow infection control protocols during wound care for a resident with a stage IV pressure ulcer and multiple comorbidities. LPNs and a CNA did not perform hand hygiene between glove changes, exited and re-entered the room wearing the same PPE, and did not remove gowns and gloves before leaving the room, contrary to facility policy and EBP requirements. The DON confirmed these actions were not consistent with established infection control procedures.
A resident with severe cognitive impairment and chronic pain received morphine sulfate solution as ordered, but the administration of this narcotic was not consistently documented on the medication administration record (MAR). Controlled drug records showed doses were signed out on multiple occasions, but corresponding entries were missing from the MAR, as confirmed by the DON. Facility policy requires immediate documentation of medication administration, which was not followed in this case.
The facility failed to label and date prepared foods in the refrigerator, affecting all residents receiving food from the kitchen. During a kitchen tour, it was found that trays of sandwiches, bowls of mandarin oranges, and cups of juice were not labeled or dated. The Kitchen Supervisor confirmed this oversight, which was against the facility's Dietary/Food Handling policy.
The facility failed to serve specialized diets as planned by the RD, affecting 15 residents. Residents with orders for puree and mechanical soft food textures did not receive the appropriate vegetables as per the diet spreadsheet. Observations revealed that none of the affected residents received the correct textured vegetables, and interviews confirmed that the diet spreadsheet was not followed during meal preparation.
A resident with cognitive impairments and a history of elopement risk managed to leave a secured unit unsupervised. The resident was last seen in the smoking room by an STNA, who lost sight of him while lighting a cigarette. The resident exited through a stairwell and was found by police outside the facility. He was returned without injury after 40 minutes.
The facility did not follow posted menus and failed to notify residents of meal changes, affecting 88 residents. Meals served on two consecutive days did not match the posted menus due to a lack of preparation and running out of certain food items. The Dietary Supervisor confirmed the discrepancies and acknowledged that residents were not informed of the changes.
The facility did not follow meal recipes, serving a meal that was visually unappealing and inconsistent with the menu. Residents expressed dissatisfaction, and the Dietary Supervisor confirmed the discrepancy, affecting nearly all residents.
The facility failed to ensure proper use of hairnets by dietary staff, affecting food safety for 88 residents. A dietary aide and a cook were observed with their braids not fully covered by hairnets while preparing and serving meals, contrary to facility policy.
A facility failed to ensure residents were fed in a dignified manner, as observed when an STNA stood behind a resident in a geri-chair, reaching around to feed them without facing them. The STNA cited a cart blocking her way as the reason for standing. This incident was noted during a complaint investigation, highlighting a breach in the facility's policy on resident dignity.
A resident with a physician's order for compression stockings to treat edema was not provided with them, despite asking. The LPN confirmed the order but did not apply the stockings, citing occasional refusals by the resident, yet failed to document any refusals. The resident was observed multiple times without the stockings, resulting in leg swelling.
A resident with multiple diagnoses and moderately impaired cognition was not seen by a physician as required due to the resident's refusal to participate in medical visits. The facility's policy required physician visits every 30 days for the first 90 days after admission, but the resident was only seen by a physician once, a PA once, and an NP twice, leading to a deficiency.
Unsanitary food storage and handling practices
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen. During observation of the dietary area, two deep freezers contained debris and scum at the bottom, and one freezer held 100 unlabeled and undated strawberry shortcakes and 50 unlabeled and undated vanilla pudding cups. One deep freezer did not have a thermometer. The food preparation area also had no soap in the hand hygiene dispenser, and a box of hair nets contained a dirty used facemask and two used hair nets. The walk-in freezer contained two unlabeled and undated pitchers of juice, and the walk-in refrigerator contained 10 unlabeled and undated sandwiches, 25 cups of pre-poured cranberry juice, and 25 cups of pre-poured water. The Dietary Manager confirmed the debris, missing thermometer, unlabeled and undated items, lack of soap, and contaminated hair net box. During breakfast preparation, the Dietary Manager used a ladle to scoop pancake batter onto the griddle, used a spatula to flip the pancakes, and then moved the pancakes to a pan on the tray line with gloved hands. After placing a stack of pancakes in the pan, he reached over and patted the pancakes down with his gloved hands. The Dietary Manager confirmed he had touched the pancakes with the same gloved hand that had been used to touch the ladle from the pancake batter. Additional observations found the C-wing refrigerator/freezer had no thermometer in the freezer compartment, about three inches of ice buildup, and a refrigerator temperature of 50 degrees Fahrenheit with food and drink spills throughout. The resident ice cooler had a can of soda lying on top of the ice. The medical wing and men's locked unit resident refrigerator/freezers also had ice buildup, spills, and debris throughout, and staff confirmed these units needed cleaning and defrosting.
Improper Medication Labeling and Storage
Penalty
Summary
The facility failed to properly label and store medications for seven residents reviewed for medication storage. For Resident #20, who was admitted with type 2 diabetes and had an order for insulin glargine 12 units subcutaneously at bedtime, surveyors observed the insulin glargine opened but not dated. An LPN confirmed that the insulin had not been dated when opened. For Resident #55, who was admitted with diabetes mellitus and had an order for Novolog insulin per sliding scale that was later discontinued, surveyors observed the Novolog insulin opened and not dated, and the LPN confirmed it remained in the cart even though it had been discontinued and had not been dated upon opening. Surveyors also reviewed orders for Residents #7, #58, and #75 for multivitamins with minerals tablets, and for Residents #36 and #37 for guaifenesin liquid. In medication storage room one, they observed five bottles of multivitamin and mineral tablets and four bottles of guaifenesin liquid that were expired. The DON confirmed that the expired bottles should have been discarded. The facility policy titled Medication Administration stated that the nurse should verify the expiration date of all medications.
Failure to Follow Two-Person Assist Care Plan During Bed Bath Resulting in Fall
Penalty
Summary
A resident with diagnoses including cerebral infarction, hemiplegia and hemiparesis of the left non-dominant side, and paranoid schizophrenia was assessed as a moderate fall risk and was documented on the MDS as moderately cognitively impaired and dependent on staff for toileting, dressing, bathing, personal hygiene, and turning and repositioning. The resident’s care plan, initiated shortly after admission, identified self-care deficits, impaired cognition, and fall risk related to hemiplegia/hemiparesis, and specified that two staff were to assist with daily hygiene, grooming, and dressing. Facility policy on accidents and incidents stated that interventions would be implemented to prevent falls. On the morning of the incident, a CNA provided incontinence care and a bed bath to the resident without a second staff member present, contrary to the resident’s care plan. The CNA rolled the resident toward the wall to perform care, then turned away from the resident to clean the bed and retrieve dry linens. While the CNA’s back was turned, the resident began to slide out of bed, feet first and then to his knees. The CNA called for help, and an RN responded and assisted the CNA in returning the resident to bed using a Hoyer lift. The facility’s fall investigation, as confirmed by the DON and RN, determined that the resident required two-person assistance for bed baths and transfers, and that the CNA did not follow the care plan, resulting in a witnessed fall without injury.
Call Light Out of Reach for Dependent Resident
Penalty
Summary
The facility failed to ensure a resident’s call light was within reach. Resident #47 had diagnoses including chronic kidney disease, cardiomegaly, peripheral vascular disease, and schizoaffective disorder. The resident’s MDS assessment showed moderate cognitive impairment and dependence on staff for assistance with ADLs, and the care plan directed staff to encourage use of the call light to request assistance. During observation, the resident was lying in bed with the call light hanging on the wall out of reach. The resident stated concern about not being able to reach the call light because she was dependent on staff for help, and a CNA later verified that the call light was out of reach.
Dirty Air Conditioning Unit in Resident Room
Penalty
Summary
The facility failed to ensure a clean and sanitary environment for Resident #38 by allowing the wall air conditioning unit next to the resident’s bed to remain covered with a black substance. Resident #38 was admitted on 02/15/23 with diagnoses including obsessive-compulsive disorder, delusional disorder, psychosis, and major depressive disorder, and the MDS dated 03/21/26 indicated the resident was cognitively intact and required supervision with ADLs. During observation on 04/13/26, the air conditioning unit was seen coated with the black substance. The resident stated he was concerned about the substance because he believed it could negatively affect his health, and a CNA confirmed the unit was coated with the black substance and should be kept clean. The facility policy stated that walls, blinds, and window curtains in resident areas would be kept clean when visibly contaminated or soiled.
Hand Hygiene Not Performed During Medication Administration
Penalty
Summary
The facility failed to ensure nurses performed appropriate hand hygiene during medication administration. During observation of medication pass, an LPN popped Resident #11’s medications out of the package into her bare hand and placed the pills in the medication cup. When interviewed, the LPN confirmed she should not touch resident medications with her bare hand. During another medication administration observation, the same LPN did not wash or sanitize her hands before administering medications to Resident #76, and she later confirmed she had not washed or sanitized her hands prior to that medication pass. In a separate observation, an LPN sanitized her hands before giving routine medications to Resident #38, but after the resident requested pain medication and the nurse returned to the medication cart to retrieve it, she did not wash or sanitize her hands before administering the additional medication. The facility policy stated that handwashing was the first step in medication administration and that hands should be washed before proceeding to the next resident.
Failure to Offer Pneumococcal and Influenza Vaccines
Penalty
Summary
The facility failed to ensure that residents were offered the pneumococcal vaccine upon admission and annually, affecting three of five residents reviewed for vaccines. Resident #22, admitted with diagnoses including alcoholic cirrhosis of the liver without ascites, unspecified dementia, and schizophrenia, received one pneumonia vaccine on 10/17/25, but the facility did not offer additional pneumonia vaccines. Resident #2, admitted with diagnoses including anoxic brain damage, hypertension, and chronic diastolic heart failure, was not offered the pneumonia vaccine or the influenza vaccine upon admission. Resident #38, admitted with diagnoses including chronic obstructive pulmonary disease, major depressive disorder, and diabetes mellitus, was not offered the pneumonia vaccine upon admission. The DON confirmed that Resident #22 was not offered or given another pneumonia vaccine after 10/17/25, Resident #2 was not offered or given the pneumonia or influenza vaccines, and Resident #38 was not offered the pneumonia vaccine. The facility policy titled Pneumococcal Vaccine dated January 2026 stated that all residents would be offered pneumonia vaccines to aid in preventing infection.
Failure to Offer and Document COVID-19 Vaccination
Penalty
Summary
The facility failed to offer COVID-19 vaccines to residents upon admission and annually, and failed to properly document vaccination status for the residents reviewed. Medical record review showed that Resident #2, admitted with diagnoses including anoxic brain damage, hypertension, and chronic diastolic heart failure, was not offered the COVID-19 vaccine upon admission. Medical record review also showed that Resident #38, admitted with diagnoses including COPD, major depressive disorder, and diabetes mellitus, was not offered the COVID-19 vaccine upon admission. During interview, the DON confirmed that Residents #2 and #38 were not offered the COVID-19 vaccine upon admission. Review of the facility policy titled COVID-19 Protocols stated that residents would be educated on the risks and benefits of the COVID-19 vaccination, offered the vaccination, and that vaccination information should be documented in the resident's medical record.
Failure to Investigate and Document Resident Falls and Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that falls experienced by residents were thoroughly investigated, properly documented, and that appropriate post-fall assessments and interventions were implemented. In one instance, a resident with dementia, delusional disorder, and Alzheimer's disease experienced an unwitnessed fall and was found on the floor with no documented fall interventions or post-fall evaluation. On a separate occasion, the same resident had another fall, was found with injuries, and was sent to the emergency room, but there was no documentation of a thorough investigation, fall risk assessment, or post-fall evaluation. The Director of Nursing (DON) and the responsible LPN confirmed that required documentation and assessments were not completed, and immediate interventions were not put in place. Additionally, during observation, the resident's call light was not within reach and non-skid strips were missing, contrary to care plan interventions. Another resident, diagnosed with paranoid schizophrenia, dementia, and other conditions, was also found to have experienced an unwitnessed fall. The only immediate intervention documented was a reminder to use the call light, and there was no evidence of a post-fall evaluation being completed. The care plan for this resident included fall risk assessments and environmental safety measures, but these were not followed after the incident. The DON confirmed that the post-fall evaluation was not completed for this resident. Review of the facility's policy indicated that all falls or suspected falls should be considered incidents requiring thorough investigation, documentation, and follow-up. Staff were expected to document specific details in the medical record and initiate accident/incident reports promptly. However, in both cases, the facility did not adhere to its own protocols, resulting in incomplete documentation, lack of timely assessments, and failure to implement or maintain required fall prevention interventions.
Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
During a wound care observation for a resident with multiple diagnoses including hemiparesis, Alzheimer's dementia, peripheral vascular disease, and a stage IV pressure ulcer, staff failed to adhere to proper infection control techniques as outlined in facility policy. The resident was under Enhanced Barrier Precautions (EBP) due to the presence of a wound. Staff involved in the dressing change initially performed hand hygiene and donned gowns and gloves. However, during the procedure, one LPN exited the resident's room wearing the same isolation gown to retrieve wound cleanser and re-entered without changing the gown. Additionally, gloves were changed multiple times without performing hand hygiene between glove changes, contrary to policy requirements. Further, after completing the wound care, the LPN exited and re-entered the room with the same gown and gloves to date and initial the dressing, again failing to remove PPE as required. Interviews with the LPN and the Director of Nursing confirmed that these actions did not comply with facility policies for EBP and aseptic dressing changes, which require removal of gowns and gloves before exiting a resident's room and performing hand hygiene between glove changes. The facility's policies were reviewed and confirmed to include these steps, but staff did not follow them during the observed wound care procedure.
Failure to Supervise Resident with Exit-Seeking Behaviors Resulting in Elopement and Injury
Penalty
Summary
A resident with a history of traumatic brain injury, schizoaffective disorder, severe cognitive impairment, and documented exit-seeking behaviors was admitted to the facility with recommendations for one-to-one staff support as needed. The resident's care plan included interventions for high elopement risk, such as secured unit placement, observation for changes in mental status, and one-to-one supervision when necessary. Despite these interventions, the resident continued to display delusions, disorganized thinking, mood swings, and paranoia, and had previously made statements about leaving the facility and jumping out of a window. On the day of the incident, multiple staff members observed and reported concerning behaviors by the resident, including entering another resident's room inappropriately, attempting to take excessive food, and making explicit threats to jump out of a window. These threats were communicated to various staff, including a CNA, an activity assistant, and an LPN. However, the LPN did not assess or remain with the resident after being informed of the threats, instead allowing the resident to return to his room alone. Other staff members either dismissed the seriousness of the threats or failed to communicate them to the appropriate personnel. At the time of the incident, the LPN was reported by some staff to be sleeping at the nursing station, though the LPN denied this. Shortly after the threats were made and reported, the resident broke a second-story window and exited the building by jumping out, resulting in an open fracture to the left ankle. The resident was found on the ground outside the unit and was subsequently transported to the hospital for treatment. The facility's investigation revealed that staff did not provide adequate supervision or timely intervention in response to the resident's exit-seeking and self-harm threats, which directly led to the elopement and injury.
Removal Plan
- The Director of Nursing (DON) and the Assistant Director of Nursing (ADON) interviewed staff from the unit to gather statements regarding the incident.
- The DON and ADON provided education to current staff on suicidal and threatening behavior protocols and interventions, behavior management, and how to deal with challenging behaviors and the need to immediately respond to resident threats of self-harm.
- Staff were instructed that the resident should not be left alone or out of line of sight for their safety. If the nurse does not respond, then they should notify the DON/ADON/Administrator.
- The DON and the ADON reviewed the suicidal ideation (SI) risk assessment/questionnaire.
- The DON and the ADON educated staff on the abuse and neglect policies and procedures.
- The DON notified staff who were not present on the date(s) of the incident via online communication that they must report to the DON/ADON for education before their next scheduled shift.
- Ongoing training will continue for all employees who have not yet received it due to paid time off (PTO), sick leave, etc., and will also be provided to all new hires.
- The ADON completed suicide risk assessments and elopement assessments for all current residents on the male secured unit, and no other residents were identified with suicidal ideations or increased/current immediate elopement risk.
- The Maintenance Director (MD) audited all second-floor windows to ensure they were secured and in place with no further issues noted.
- Staff secured Resident #11's room to prevent re-entry and cleared glass debris from the courtyard for safety.
- The facility Administrator opened a Self-Reported Incident (SRI) and reported the incident to the Ohio Department of Health (ODH).
- The Administrator suspended Licensed Practical Nurse (LPN) #205 who was the unit nurse at the time of the incident, pending the outcome of the investigation.
- The Administrator and the DON notified the Medical Director and a member of the governing body (GB)/Owner of the incident.
- The facility held an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting by phone with the Administrator, the DON, the Medical Director and the Facility Owner.
- The Administrator and the DON completed a root cause analysis of the incident and determined the root cause was staff did not stay with Resident #11 when the resident verbalized an intent to leave the facility by jumping out a window and LPN #205 failed to assess Resident #11 when notified by staff.
- The ADON began questioning random staff three times weekly to verify knowledge of resident safety protocols. Results are turned into the Administrator for ongoing monitoring and compliance. The ADON will continue the monitoring three times weekly for three months.
- The management team will conduct ongoing education and continue to address any issues related to suicidal and threatening behaviors.
- Staff have been and will continue to be questioned by the Administrator or designee on appropriate actions to take if a resident expresses an intent to harm themselves. This will be conducted three times per week for three months, and results will be reported to the QAPI committee.
- The facility Psych Nurse Practitioner (NP) and outside counseling service representatives met with all residents on the secured male unit to provide support.
- RCO #800 provided re-education to the current Administrator and the acting Administrator at the time of the incident on the importance of a thorough investigation and the need to review the accuracy and information provided by staff.
- The Administrator notified LPN #205 that after investigation LPN #205's employment was terminated.
Failure to Maintain Infection Control During Wound Care
Penalty
Summary
During wound care for a resident with multiple diagnoses including hemiparesis, Alzheimer's dementia, peripheral vascular disease, and a stage IV pressure ulcer, staff failed to maintain proper infection control techniques as required by facility policy and Enhanced Barrier Precautions (EBP). The resident was dependent on staff for activities of daily living and required EBP due to the presence of a severe wound. Observations revealed that staff did not consistently perform hand hygiene between glove changes, exited and re-entered the resident's room wearing the same gown and gloves, and failed to remove personal protective equipment (PPE) before leaving the room. Supplies were not gathered prior to beginning care, resulting in staff leaving the room mid-procedure while still wearing PPE. Interviews with staff and the Director of Nursing confirmed that these actions were not in accordance with facility policies for aseptic dressing changes and EBP, which require hand hygiene at specific points during wound care and the removal of gowns and gloves before exiting a resident's room. The facility's own policies outlined the necessary steps for infection prevention, but these were not followed during the observed wound care procedure for the resident.
Failure to Document Narcotic Administration on MAR
Penalty
Summary
The facility failed to ensure that the administration of a narcotic pain medication, morphine sulfate solution, was consistently documented on the medication administration record (MAR) for a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease, osteoporosis, uterine cancer, and chronic pain. The resident, who had transitioned to hospice care, had a physician's order for morphine to be administered as needed for pain or dyspnea. Review of the MARs for September, October, and December 2024 showed that not all doses of morphine signed out on the controlled drug record were documented as administered on the MAR. For example, doses were signed out on the controlled drug record on several dates, but corresponding documentation was missing from the MAR on those same dates. Interviews with the Director of Nursing confirmed that medications must be documented on the MAR when given, and verified the discrepancies between the controlled drug records and the MARs for the resident. Facility policy also requires that medications be documented on the MAR as soon as they are administered. The failure to document the administration of morphine as required by policy and physician order resulted in incomplete records for the resident's pain management.
Failure to Label and Date Prepared Foods in Refrigerator
Penalty
Summary
The facility failed to properly label prepared foods in the refrigerator, which had the potential to affect all residents receiving food from the kitchen. During an observation and interview with the Kitchen Supervisor, it was revealed that there were two trays of sandwiches, one tray of bowls of mandarin oranges, and three trays of cups of juice that were not labeled or dated inside the refrigerator. The Kitchen Supervisor confirmed that these items were not labeled or dated and acknowledged that they should have been. A review of the facility's Dietary/Food Handling policy, dated January 2023, indicated that food is to be dated and labeled upon arrival from the vendor and/or upon preparation. This deficiency was investigated under Complaint Number OH00162926, with the facility census being 85 at the time of the observation.
Failure to Serve Specialized Diets as Planned
Penalty
Summary
The facility failed to serve specialized diets as planned by the Registered Dietitian (RD), affecting 15 residents out of 89 who were receiving food from the kitchen. The deficiency was identified through interviews, observations, and record reviews. Specifically, residents with physician orders for puree and mechanical soft food texture consistencies did not receive the appropriate textured vegetables as per the lunch menu diet spreadsheet. Residents #01 and #69 were supposed to receive puree green beans, while the other affected residents were to receive green beans in a mechanical soft texture. During the lunch meal service, it was observed that none of the affected residents received green beans or any other similar vegetable. An interview with a staff member confirmed the oversight, revealing that the diet spreadsheet, which was available for review during meal preparation, was not followed. The RD also verified that the diet spreadsheet was accessible for cooks to prepare the textured diet foods and confirmed that the residents did not receive the correct alternate food for their prescribed diet textures. The facility's policy on Spreadsheet Guidelines for Menu Planning indicated that spreadsheets are designed to meet therapeutic requirements, but this was not adhered to, leading to the deficiency.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident with a history of schizophrenia, dementia, and other medical conditions. The resident, who was admitted to a secured unit due to cognitive impairments and elopement risk, was last seen in the smoking room by a State Tested Nurse Aide (STNA). The STNA provided the resident with an unlit cigarette, and upon attempting to light it, discovered the resident was missing. The resident had exited the facility through a stairwell adjacent to the smoking room. The staff immediately searched for the resident both inside and outside the facility but were unable to locate him. The local police, who were investigating a potential break-in nearby, found the resident walking around outside the facility and returned him 40 minutes later. The resident was assessed upon return and found to have no injuries. The incident was verified by the Assistant Director of Nursing and the Administrator, confirming the resident's elopement through the stairwell while under the supervision of the STNA.
Failure to Follow Menus and Notify Residents of Changes
Penalty
Summary
The facility failed to ensure that menus were followed and that residents were notified of menu changes prior to meals, affecting 88 of 89 residents. During observations, it was noted that the posted menus did not match the meals served on two consecutive days. On the first day, the menu listed a baked pork chop, stuffing, green beans, and a dinner roll, but residents were served turkey and rice casserole, green peas, and a biscuit instead. On the following day, the menu indicated turkey and rice casserole, green peas, and a biscuit, but residents received shredded pork, potatoes with peas, and a roll. The Dietary Supervisor admitted that the meals served did not match the posted menus and that residents were not informed of these changes beforehand. The discrepancy occurred because the meal scheduled for the first day was not taken out to thaw, leading to the turkey and rice casserole being served instead. Additionally, the facility ran out of biscuits, further contributing to the inconsistency. The failure to notify residents of these changes was verified by the Dietary Supervisor, who acknowledged that residents should have been informed prior to the meals.
Failure to Follow Meal Recipes and Ensure Food Appeal
Penalty
Summary
The facility failed to ensure that meals were prepared according to the specified recipes and that the food served was visually appealing. On 06/03/24, the menu indicated that residents were to receive an open-faced turkey sandwich with gravy, mashed potatoes, and a California vegetable blend for lunch. However, observations revealed that residents were served a piece of white bread with chopped meat and a reddish-brown gravy, which did not match the recipe. The mashed potatoes and mixed vegetables were served on the side, contrary to the menu's description. Multiple residents expressed dissatisfaction with the meal's appearance, comparing it to dog food and stating it looked unappetizing. The Dietary Supervisor confirmed that the meal served did not match the recipe, noting that the meat was cubed instead of sliced and the gravy was not turkey gravy. The discrepancy was attributed to the correct food not being taken out to thaw, affecting 88 of the 89 residents in the facility.
Improper Use of Hairnets in Food Service
Penalty
Summary
The facility failed to ensure that employees wore hairnets properly while preparing and serving food and beverages, which had the potential to affect 88 of 89 residents. During an observation, a dietary aide was seen at the juice machine without a hairnet, and upon being instructed to wear one, did not fully cover his braids. Similarly, a dietary cook was observed with her braids sticking out of her hairnet while stirring food at the steam table and plating meals. The dietary supervisor confirmed that both employees did not have their hair fully covered, which was against the facility's policy requiring hairnets in food service areas.
Failure to Feed Resident in a Dignified Manner
Penalty
Summary
The facility failed to ensure that residents were fed in a safe and dignified manner, specifically affecting one resident. During an observation, a State tested Nursing Assistant (STNA) was seen standing in the hallway at the nurse station, feeding a resident who was seated in a reclining geri-chair. The STNA was positioned behind the resident, reaching around to put food into the resident's mouth, rather than facing the resident. The STNA stated that she was standing because a cart containing trays for the lunch meal was in her way, but did not provide a reason for not facing the resident while feeding. The facility's policy on Resident Rights and Dignity, which was undated, indicated that all residents should be treated in a dignified manner. This deficiency was identified during a complaint investigation.
Failure to Apply Compression Stockings as Ordered
Penalty
Summary
The facility failed to ensure that a resident's compression stockings were applied as ordered to treat edema. This deficiency affected one resident, who had a physician's order to apply compression wraps to bilateral lower extremities in the morning and remove them at night. Despite the order, the resident was observed multiple times without the compression hose, and the resident reported not being provided with them despite asking. The Licensed Practical Nurse (LPN) confirmed the resident had an order for compression hose but did not apply them, citing that the resident sometimes refused them. However, there was no documentation of any refusal by the resident on the days observed. The LPN acknowledged the responsibility to ensure the compression hose were applied as per the physician's order, yet failed to do so, resulting in the resident experiencing swelling in her legs.
Failure to Ensure Required Physician Visits
Penalty
Summary
The facility failed to ensure that a resident was seen by a physician as required, affecting one of the three residents reviewed for physician visits. The resident, who was admitted with multiple diagnoses including nerve root and plexus disorder, Wernicke's encephalopathy, alcohol abuse with alcohol-induced sleep disorder, insomnia, legal blindness, depression, anxiety, and iron deficiency anemia, had moderately impaired cognition according to the comprehensive Minimum Data Set (MDS) assessment. The resident was seen by the physician on one occasion, by a physician assistant on another, and by a nurse practitioner twice, but not at the required frequency of every 30 days during the first 90 days of admission. Interviews with the Director of Nursing (DON) and the Medical Director (MD) revealed that the resident was not seen by the physician as required due to the resident's refusal to participate in medical visits, preferring to remain on the phone. The physician attempted to see the resident on two occasions, but the resident did not cooperate. The facility's policy stated that the physician should see the resident once every 30 days for the first 90 days after admission, with a qualified nurse practitioner or physician assistant allowed to make every other required visit. However, the resident's refusal and the lack of further attempts by the physician to conduct the visit contributed to the deficiency.
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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) |
|---|---|---|---|---|
| Harmony Court Rehab And Nursing | 0.7 mi | ★★★★★ | 22 | 1 |
| Norwood Towers Post-acute | 1.5 mi | ★★★★★ | 30 | 0 |
| Daniel Drake Center For Post-acute Care Llc | 2.1 mi | — | 0 | 0 |
| Wellspring Health Center | 2.3 mi | ★★★★★ | 13 | 0 |
| Astoria Place Of Cincinnati | 2.5 mi | ★★★★★ | 42 | 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.