Advanced Health Care of Cincinnati

Inspectors wroteBased on medical record review, observation, staff interview, manufacturer directions and policy review, the facility failed to ensure medications were administered as ordered. There were four medication errors out of 26 opportunities for error which resulted in a 15.38 percent medication error rate. This affected four (#17, #18, #19, #20) of five residents reviewed for medication administration. The facility census was 34. Findings Include:1. Review of the medical record for Resident #19 revealed an admission date of 10/29/25. Diagnoses included metabolic encephalopathy and rhabdomyolysis. Review of the physician orders for Resident #19 revealed an order for a chewable 81milligram (mg) Aspirin tablet with a start date of 10/30/25. Observation on 11/05/25 at 7:39 A.M. [...]

Inspectors wroteBased on policy review, observation, and staff interview, the facility failed to store and prepare food in a manner that kept food safe. This had the potential to affect all 29 residents residing in the facility who received food from the kitchen. The facility census was 29.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to implement their water management plan to reduce the risk of Legionella (bacteria that causes a severe form of pneumonia with exposure generally from droplets of water). This had the potential to affect all 29 residents residing in the facility.

Inspectors wroteBased on record review, review of the self-reported incident (SRI), review of time punch card, staff interview, and policy review, the facility failed to follow their abuse policy following a staff-to-resident abuse allegation. This affected one (#87) of four residents reviewed for abuse. The facility census was 29.

Inspectors wroteBased on record review and staff and resident interviews, the facility failed to explain the arbitration agreement in a manner that residents could understand. This affected two (#9 and #14) of four residents reviewed for arbitration agreements. The facility identified there were four residents who recently signed arbitration agreements. The facility census was 29.

Inspectors wroteBased on record review, staff interview, and review of facility policy, the facility failed to provide timely and complete access to resident medical records. This affected one resident (#17) of three residents reviewed. The facility census was 13.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were visited by a physician every 60 days. This affected four (Residents #05, #06, #10, and #31) of four residents reviewed for physician visits. The facility census was 39.

Inspectors wroteBased on record review, interview and policy review, the facility failed to hold Quality Assessment and Assurance meetings at least quarterly. This had the potential to affect all 39 residents in the facility. The facility census was 39.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's advanced directives were ordered and placed on the resident chart accurately. This affected one Resident (#45) out of three residents reviewed for advanced directives. The facility census was 39.

Inspectors wroteBased on record review, interview and policy review, the facility failed to ensure the Minimum Data Set (MDS) assessment was completed accurately to reflect a resident's current health care status. This affected one (Resident #5) of three residents reviewed for accurate MDS assessments. The facility census was 39.

Inspectors wroteBased on record review, interview and policy review, the facility failed to notify the resident, representative or Ombudsman in writing of a transfer from the facility. This affected five (Residents #5, #8, #26, #7 and #44) of five residents reviewed for transfer notices. The facility census was 39.

Inspectors wroteBased on medical record review, staff interview, observations and facility policy review, the facility failed to ensure a written bed hold policy was given to the resident prior to transfer from the facility. This affected five residents (#8, #5, #26, #27, #44) of five residents reviewed for bed hold policy. The facility census was 39.

Inspectors wrote4. Closed record review revealed Resident #73 was admitted on [DATE] with diagnoses including history of myocardial infarction, dementia and congestive heart failure. Review of Resident #73's progress note dated 04/19/19 revealed resident was transferred to the hospital on [DATE] at 8:17 A.M. Review of Resident #73's medical record revealed no evidence that a bed hold notice or a transfer/discharge notice was provided to the resident or the resident's representative. Interview on 07/02/19 at 3:58 P.M. with VPCC #800 confirmed the facility did not provide a transfer/discharge notice for Resident #73 after being emergently transferred and admitted to the hospital on [DATE]. [...]

Inspectors wroteBased on observation, staff interview, the facility failed to label, date and discard expired food items from the walk-in refrigerator and freezer. This had the potential to affect 29 out of 30 residents in the facility, one resident was ordered to receive nothing by mouth (NPO). Facility census was 30.

Inspectors wroteBased on record review and interview, the facility failed to allow a resident to attend a care conference. This affected one (Resident #180) of 16 residents reviewed for care conferences. The census was 30. Review of resident records revealed an admission date of 06/19/19 with diagnoses including osteomyelitis, contusion of left lesser toe with damage to nail, peripheral vascular disease, major depression, type two diabetes, local infection to skin. The minimum data set (MDS) assessment dated [DATE] revealed resident was cognitively intact and was independent for walking in room and toileting, independent with set-up for eating and personal hygiene, supervision and set-up for transfers, walking in hallway, locomotion, and bathing, and limited one assist for bed mobility and dressing. He was his own responsible party. Interview on 06/30/19 at 12:14 P.M. [...]

Inspectors wroteBased on interview and medical record review, the facility failed to ensure Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) was provided when skilled services ended and the resident remained at the facility. This affected one (Resident #5) of three reviewed for Beneficiary Protection Notification. The facility census was 30.

Inspectors wrote2. Medical record review revealed Resident #5 was admitted to the facility on [DATE]. The resident was discharged to the hospital on [DATE] and returned to the facility on [DATE]. Review of nursing progress note dated 03/24/19 at 11:38 P.M. revealed Resident #5 was transported to the hospital for an acute change in condition. Review of nursing progress note dated 04/03/19 at 11:16 P.M. revealed Resident #5 returned to the facility at 3:00 P.M. from the hospital. There was no documentation in the medical record that the resident or the resident's representative were notified about the facility bed hold policy upon hospitalization. Interview on 06/30/19 at 10:29 A.M. with Resident #5 reported several hospitalizations since admitted to the facility. Interview on 07/02/19 at 3:55 P.M. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident received needed foot care. This affected one (Resident #7) of one reviewed for activities of daily living (ADL). The facility census was 30.

Inspectors wroteBased on observation, interview and medical record review, the facility failed to ensure transportation services were arranged for scheduled medical appointments in the community. This affected one (Resident #7) of 12 residents investigated during the survey.

Inspectors wroteBased on observation and interview, the facility failed to ensure nursing staffing information was posted daily. This affected all 30 residents at the facility.