Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Schoenbrunn Healthcare during CMS and state inspections, most recent first.
Surveyors found that the facility failed to employ a qualified director of food and nutrition services and to ensure education of dietary aides, affecting all 86 residents. A contract company assumed operation of the kitchen and promoted a former cook to Dietary Manager despite her lacking required certification and relevant educational background. The previously credentialed Dietary Manager stepped down due to the complexity of the new computer system and informed the company that the new Dietary Manager was not credentialed. Although the company indicated it would fund certification training, the new Dietary Manager had not begun any classes at the time of the survey, resulting in non-compliance related to food and nutrition services oversight.
Food was not prepared in a manner that conserved flavor and appearance, as evidenced by a resident repeatedly receiving chicken noodle soup without broth, resulting in bowls of dry noodles that had to be eaten with a fork, and by broccoli consistently served in a mushy, watery state that did not hold its shape. Staff, including dietary personnel, acknowledged that the soup tin contained no broth and that the broccoli always became mushy due to the way it was cooked on the stovetop in a tin on low heat.
The facility failed to provide alternate meal choices of similar nutritional value and did not consistently honor resident food and beverage preferences during a period when the main kitchen was closed and meals were prepared from the dining room using limited equipment. Only a single entrée was offered at each meal, with peanut butter and jelly or deli sandwiches as the only substitutes, and several residents reported they could not order and were simply served whatever was prepared, including food they disliked or items that did not match their stated preferences. Residents also did not consistently receive requested beverages such as chocolate milk, 2% milk, cranberry juice, fruit punch, or ice with meals, and one resident reported being served burnt pizza with no alternative. The Dietary Manager confirmed there was no second meal option of similar nutritive value during the shutdown and that new dietary aides had not been fully trained on tray line duties.
Surveyors found that kitchen sanitation and milk handling practices were deficient. An uncovered, overflowing trash can was located next to a food prep area where a dietary aide was portioning fruit. Staff did not consistently monitor milk temperatures, and milk was sometimes served above the 41°F guideline despite a policy requiring cold potentially hazardous foods to be held at or below that temperature. Temperature logs showed many meals without recorded milk temperatures, and expired milk cartons remained in the milk chest, with expired milk served to a resident.
A cognitively intact, fully dependent and always incontinent resident received incontinence care from a CNA in a shared room without the privacy curtain being drawn, despite the roommate being present. During the care, the resident’s genital area and buttocks were exposed while the CNA removed the adult brief and cleaned the resident. The resident later reported that staff sometimes forget to pull the curtain and that this exposure sometimes bothers him, and the CNA acknowledged not using the privacy curtain, contrary to facility policy on resident privacy during personal care.
A resident with renal failure and legal blindness, who required set-up assistance for meals, had physician orders for a renal diet with specific food restrictions and the use of a blue scoop bowl and plate guard. During multiple observed meals, the tray line provided only a plate guard and no scoop bowl, despite the meal ticket indicating the need for both. Dietary staff reported that previously available scoop bowls could no longer be found anywhere in the facility, resulting in the resident not receiving the ordered adaptive equipment during the observed meal services.
The facility did not maintain complete and accurate medical records for several residents, failing to document activity participation and medication administration as required. For multiple residents with complex medical and psychosocial needs, activity participation was not recorded in the official medical record for several months, despite care plans indicating its importance. Additionally, discrepancies were found between the controlled substance records and the MAR for a resident receiving oxycodone, with doses not properly documented as administered. These issues were confirmed by the Activity Director and DON during a complaint investigation.
A resident with multiple chronic conditions and cognitive impairment did not receive an individualized activity program tailored to her documented preferences for group activities, crafts, and socialization. Despite her ability to communicate and express interest in participating if reminded, staff did not consistently provide reminders or re-evaluate her activity plan, and activity participation logs were missing for two months. The activity calendar offered limited variety, and the resident was mostly observed in bed with passive engagement, leading to a deficiency in meeting her activity needs.
A resident experienced verbal and emotional abuse from an STNA who yelled, used profanity, and punched a wall during care. The incident was not reported to management until days later, allowing the STNA to continue working with the resident. The facility's delayed response and failure to adhere to abuse policies resulted in psychosocial harm to the resident.
An LPN at a facility was found with medication packages belonging to 13 residents in her vehicle, leading to a misappropriation incident. The medications, including Mirtazapine and Metoprolol, were discovered by the LPN's family and reported to the police. The facility's investigation could not determine if residents missed doses, and the LPN was receiving treatment at the time of the report.
A resident reported an incident where an STNA punched a wall in frustration, causing fear. The incident was not reported to the Administrator until several days later, contrary to the facility's policy requiring immediate reporting of abuse allegations. Staff interviews revealed a misunderstanding about the nature of the incident and a delay due to the Administrator's unavailability.
A facility failed to develop a discharge plan of care for a resident with complex medical needs, including cerebral infarction and diabetes mellitus type-1. Despite communication between the resident's power of attorney and the Social Service Designee (SSD) about necessary home care products and services, no active discharge planning or referrals were made. The SSD did not create a discharge plan due to concerns about forgetting updates, and the facility's policy for discharge planning was not adhered to.
A facility failed to revise a resident's care plan to reflect their preference against male caregivers, despite being informed by the resident's power of attorney. The resident, who was cognitively intact and had specific preferences documented, received care from a male caregiver before the facility was notified and took corrective action.
The facility failed to provide tracheostomy care as ordered for two residents, leading to missed care and equipment changes. One resident with cerebral infarction and tracheitis did not receive tracheostomy care on multiple occasions, and their care plan lacked necessary interventions. Another resident with cerebral infarction and diabetes also experienced missed tracheostomy care and equipment changes, with their care plan similarly lacking interventions. The facility's policy required adherence to physician's orders and professional standards, which was not followed.
A facility failed to ensure proper gloving and hand hygiene during incontinence care for a resident with dementia and incontinence. An STNA did not change gloves or wash hands after cleansing the resident and before adjusting the resident's gown and bed linens. The facility's policies on hand hygiene and perineal care were not followed.
Unqualified Dietary Manager and Lack of Dietary Staff Education
Penalty
Summary
The deficiency involves the facility’s failure to employ a qualified director of food and nutrition services and to ensure appropriate education of dietary aides, affecting all 86 residents. The Administrator reported that a contract company, Health Care Services Group (HCSG), had been brought in to run the kitchen, using the facility’s existing kitchen staff while the facility retained oversight. Personnel credential review showed that the individual serving as Dietary Manager, identified as #217, did not meet the qualifications for the role: she was not certified and her degrees were not in fields that would qualify her as a Dietary Manager, despite her years of kitchen experience. Interviews with Dietary Manager #217 revealed that she had originally been employed as a cook and was promoted to manage the kitchen after HCSG took over operations. She stated that a previously credentialed Dietary Manager, identified as #100, stepped down from the role when the contract company assumed control, citing the complexity of the computer system, and recommended her, while informing HCSG that she was not credentialed. HCSG indicated they would pay for her to take classes to become a Certified Dietary Manager, but she confirmed she had not started any classes and believed the company might be waiting to see if she could handle the position before investing in her training. The survey identified this as a failure to employ a qualified Dietary Manager and to provide education to dietary aides, constituting non-compliance under Complaint Number 2701233.
Improper Food Preparation Affecting Soup Consistency and Vegetable Texture
Penalty
Summary
Failure to ensure food and drink were palatable, attractive, and at a safe and appetizing temperature was identified through observations, test trays, and interviews. During a lunch meal, one resident on the Lifebridge Unit, which was the last hall to be served, received two bowls of what appeared to be pasta salad on his tray at approximately 1:25 P.M. The resident clarified that both bowls were supposed to be chicken noodle soup, but there was no broth in either bowl, and he was eating the contents with a fork. He stated that he requested two bowls of chicken noodle soup daily for lunch and that sometimes there was broth, but usually he had to eat the soup with a fork. A CNA confirmed that the resident had received two bowls of chicken noodle soup without broth. On a subsequent lunch observation, the same resident again received two bowls that were supposed to be chicken noodle soup; one bowl had no visible broth and the other had only a small amount of liquid at the bottom. The Dietary Manager, present during this observation, acknowledged that the noodles appeared to be soaking up the broth and verified that the soup tin in the kitchen contained no broth, only noodles and carrots, and appeared dry at the bottom. Additional observations during the dinner tray line showed that broccoli being served did not maintain its shape and appeared mushy and watery. When a test bowl of broccoli was served later in the meal service, it still did not hold its shape and had a mushy, watery texture. An interview with a dietary staff member revealed that the broccoli was cooked on the stovetop in a tin on low heat, and he confirmed that the broccoli always became mushy. These findings demonstrated that food was not being prepared by methods that conserved nutritive value, flavor, and appearance, affecting items such as chicken noodle soup and broccoli and having the potential to impact all 86 residents in the facility.
Failure to Provide Alternate Meal Choices and Honor Resident Food Preferences
Penalty
Summary
The deficiency involves the facility’s failure to provide appealing meal options of similar nutritive value and to honor residents’ food preferences during a prolonged kitchen shutdown and subsequent transition period. For 19 days while major plumbing repairs were performed in the kitchen and dry storage, the facility prepared meals out of the dining room using limited equipment such as roasters, crockpots, a microwave, a griddle, and a waffle maker. During this time, only one meal choice was offered at each meal, and the only substitutes available were peanut butter and jelly sandwiches or deli sandwiches. The Dietary Manager confirmed that there was no second meal option of similar nutritional value available during the kitchen shutdown. Multiple residents reported not being able to order or receive their preferred items. One resident stated there were no second options or substitute items and that he was simply given food he did not like, including peas, carrots, and rice. Another resident’s meal ticket indicated a preference for chocolate milk, which was not provided on the tray. A different resident reported she does not order and is just served whatever is given; her stated preferences for 2% milk, cranberry juice, and fruit punch resulted in her receiving only fruit punch. Another resident reported being served burnt pizza with no other option when the kitchen was down and stated that even when she tells staff what she wants, she usually does not receive it; her ticket also indicated she should receive ice with every meal and fruit punch at lunch, neither of which were delivered. The Dietary Manager further acknowledged that new dietary aides were still in training and had not been given sufficient time to learn their tray line duties during and immediately after the kitchen relocation.
Failure to Maintain Sanitary Food Service and Proper Milk Handling
Penalty
Summary
The facility failed to store, prepare, and serve food under sanitary conditions, affecting the entire census of 86 residents. Surveyors observed that a large garbage can located near a prep table and three-compartment sink in the kitchen did not have a lid and was repeatedly overflowing with trash, including large cans piled above the rim, on multiple observations over two days. During one observation, a dietary aide was portioning pineapple into cups and covering them with plastic wrap on the prep table adjacent to the uncovered, overflowing trash can. The dietary manager confirmed that the garbage can was not covered with a lid. Surveyors also found that milk temperatures were not consistently monitored and that milk was not always maintained at or below the facility’s policy guideline of 41°F. During a supper tray line, milk temperatures were not initially taken, and when requested, a milk sample measured 40°F. On another meal service, pre-poured milk cups were left on the three-compartment sink before being placed in the milk chest, and later a glass of milk taken from the chest measured 46.9°F; staff confirmed that milk temperatures were not obtained before the tray line started. Review of March food temperature logs showed that milk temperatures were missing for 47 of 71 meals, and the dietary manager acknowledged inconsistent monitoring. Additionally, surveyors found multiple cartons of 1% milk in the milk chest past their use-by date, and a staff member reported using two expired cartons for resident trays, with one expired milk serving provided to a resident. The facility’s written policy required potentially hazardous cold foods to be kept at or below 41°F and verified with a clean, sanitized, and calibrated thermometer.
Failure to Ensure Privacy During Incontinence Care
Penalty
Summary
The deficiency involves a failure to maintain privacy during incontinence care for Resident #3. The resident was admitted with multiple diagnoses including lung disease, heart failure, diabetes, anxiety, gastric reflux, hypertension, arthritis, and a gastric bleed. A quarterly MDS assessment dated 01/14/26 documented that the resident was cognitively intact, dependent on staff for personal hygiene, toileting, bathing, dressing, transfer, and mobility, and was always incontinent of bowel and bladder. Facility policy on Resident Rights stated that residents have the right to privacy and confidentiality, including personal privacy during personal care. On 03/25/26 at 8:58 A.M., a surveyor observed CNA #137 gather supplies and enter the double-occupancy room of Resident #3, closing the door while the resident’s roommate remained in the room in his wheelchair. Although a privacy curtain divided the room, the CNA did not draw the curtain at any time during the incontinence care. The CNA removed the resident’s adult brief, exposing his genital area for cleaning, and then had him roll to his left side toward the wall, which exposed his buttocks to his roommate while care continued. During an interview at 9:04 A.M. the same day, the resident stated that CNAs sometimes forget to pull the curtain during incontinence care and that it sometimes bothers him to be exposed to his roommate when present. CNA #137, present during the interview, acknowledged she had not pulled the privacy curtain.
Failure to Provide Ordered Adaptive Eating Equipment
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered adaptive eating equipment for a resident who required it. The resident was admitted with diagnoses including hypertensive urgency, renal dialysis, glaucoma, and legal blindness. A quarterly MDS assessment documented that the resident was independent in daily decision making but required set-up assistance for meals. Physician orders specified a renal diet with regular texture and thin liquids, double protein, several food restrictions, an 1800 milliliter fluid restriction, and the use of a blue scoop bowl and plate guard related to renal failure. During a supper meal observation, the resident’s meal ticket indicated the need for both a blue scoop bowl and a plate guard, but the tray was prepared with only a plate guard. Further observations of subsequent meal tray lines showed that the required scoop bowl continued to be unavailable for the resident’s meals. At one lunch service, staff confirmed there were no scoop bowls available for the resident’s tray, despite the order specifying their use. Dietary staff interviews revealed that the facility previously had multiple scoop bowls but they could no longer locate them, and that only three had recently been available before they also went missing. Multiple staff, including dietary aides and the dietary manager, reported they were unable to find any scoop bowls in the kitchen, resident rooms, or on the units at the time of the observations. As a result, the resident did not receive the ordered adaptive equipment during the observed meals.
Failure to Maintain Complete Medical Records for Activities and Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records for several residents, specifically regarding documentation of activity participation and medication administration. For four residents with various diagnoses including COPD, dementia, depression, heart failure, and other chronic conditions, there was a lack of documented activity participation in the medical records for multiple months. Although some activity notes existed in separate notebooks or were verbally confirmed by staff, these records were not incorporated into the official medical record as required. The Activity Director confirmed the absence of activity participation documentation in the medical records since March for the affected residents, despite care plans and assessments indicating the importance of social and activity engagement for these individuals. Additionally, the facility failed to ensure accurate medication administration records for a resident prescribed oxycodone for pain management. There were multiple discrepancies between the controlled substance accountability records and the Medication Administration Record (MAR), including instances where doses were signed out from the narcotic supply but not documented as administered on the MAR. In some cases, doses were recorded late or not at all, and the timing of administration did not align with physician orders. The DON acknowledged these discrepancies and attributed them to documentation errors, noting that one nurse involved had worked seven consecutive days. These deficiencies were identified through medical record review and staff interviews, and were verified by the Activity Director and DON. The lack of proper documentation affected all four residents reviewed, and the findings were discovered during a complaint investigation.
Failure to Provide Individualized Activity Program Based on Resident Preferences
Penalty
Summary
The facility failed to ensure that an individualized activity program was developed and implemented based on a resident's preferences. The resident in question had multiple diagnoses, including COPD, anxiety, depression with psychotic symptoms, dementia with mood disturbance, and difficulty walking, and required transfer with a mechanical lift. The care plan indicated the resident should remain active and social, with interventions such as providing an activity calendar, discussing ongoing events, listening to interests, and reminding the resident of activities. The resident's documented interests included group activities, crafts, music, socialization, and community outings, and she was able to communicate her needs and preferences. Despite these documented preferences, activity participation logs showed limited engagement, with most participation being passive or involving solitary activities such as watching television or listening to the radio. There were no activity participation logs available for two consecutive months, and observations revealed the resident spent most of her time in bed with the television on, often sleeping or not actively engaged. Staff interviews indicated that activity staff did not attempt to wake the resident for activities and that there was a lack of re-evaluation of the activity plan despite the resident's limited participation and expressed interest in group activities if reminded. The activity calendars for the reviewed months showed a limited variety of activities, with many days offering only one activity repeated on different units and few individualized or preference-based options. The resident reported she would be interested in group activities, crafts, and socialization if she received reminders, but this was not consistently provided. The lack of individualized activity programming and insufficient documentation of participation led to the deficiency.
Failure to Protect Resident from Staff Abuse
Penalty
Summary
The facility failed to protect a resident from staff abuse, specifically involving intimidation, verbal, and emotional abuse. On 09/30/24, a State tested Nursing Assistant (STNA) became frustrated while providing care to a resident, yelled, used profanity, and punched the wall above the resident's bed. The resident perceived these actions as directed towards her, resulting in actual psychosocial harm. Despite the incident, the STNA continued to work additional shifts, including caring for the same resident, before being suspended and eventually terminated. The incident was not reported to facility management until 10/06/24, several days after it occurred. During this period, the resident expressed fear of retaliation and reported a lack of appetite and motivation to engage in activities. The facility's investigation revealed that other staff members had witnessed the STNA's aggressive behavior on multiple occasions, and there were concerns about his mental health and frustration levels. However, the incident was not immediately reported by the staff who witnessed it, as they did not initially perceive it as abuse. The facility's policy on abuse, neglect, and exploitation defines abuse as the willful infliction of injury, intimidation, or punishment resulting in harm or mental anguish. The policy emphasizes the need for immediate response to protect residents and maintain the integrity of investigations. Despite this, the facility did not take prompt action to protect the resident or address the STNA's behavior until several days after the incident, highlighting a failure in adhering to their own policies and ensuring resident safety.
Misappropriation of Resident Medications by LPN
Penalty
Summary
The facility failed to prevent the misappropriation of resident medications, affecting 13 residents. The incident came to light when local law enforcement informed the facility that medication packages with residents' names were found in the vehicle of an LPN. The medications included various prescriptions such as Mirtazapine, Metoprolol, and others, with some packages being unopened and others partially used. The facility's investigation revealed that the medications were dated from the previous year to the current year, and some were discontinued, some were from when residents were out of the facility, and some were marked as administered. Interviews with the facility's Administrator, a police officer, and the Director of Nursing confirmed the discovery of the medications and the ongoing investigation. The Administrator noted that the LPN was acting erratically and was taken to the hospital for evaluation, with her family later discovering the medications in her car. The police officer verified the condition of the medications, and the Director of Nursing confirmed that the medications were checked against the medication administration record, but it was unclear if any residents missed their medications due to the incident. The facility's policy defines misappropriation as the wrongful use of a resident's belongings without consent, which was violated in this case.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure timely reporting of an allegation of staff-to-resident abuse, affecting one resident. Resident #03, who was cognitively intact and had a medical history including acute and chronic respiratory failure, myocardial infarction, anxiety disorder, and major depressive disorder, reported an incident involving a State Tested Nursing Assistant (STNA #174) who became frustrated and punched a wall in the resident's room. The incident occurred on 09/30/24, but the facility's Administrator was not notified until 10/06/24, which was a delay in reporting the incident as per the facility's policy. The facility's policy requires that allegations involving abuse be reported immediately, but not later than two hours after the allegation is made. However, the incident was not reported until several days later. Interviews with staff and residents revealed that the incident was known to some staff members, but it was not escalated to the Administrator in a timely manner. The delay in reporting was partly due to a misunderstanding by STNA #100, who did not report the incident because she did not perceive it as abuse. Additionally, a nurse informed Resident #64 that the incident could not be reported until the Administrator was available, which contributed to the delay.
Failure to Develop Discharge Plan of Care
Penalty
Summary
The facility failed to develop a discharge plan of care for a resident, which was identified during a review of medical records, policy, and interviews. The resident, who was admitted with diagnoses including cerebral infarction, diabetes mellitus type-1, tracheostomy, and anoxic brain injury, was discharged without a documented discharge plan. Despite the resident's power of attorney and the Social Service Designee (SSD) communicating about the need for home care products and services, no active discharge planning or referrals were made as per the Minimum Data Set (MDS) assessment. The SSD admitted to not developing a discharge plan of care due to concerns about forgetting to update it. Although the SSD had been working on discharge arrangements for about a month before the resident's discharge, there was no evidence of a formal discharge plan. The facility's policy required an effective discharge planning process involving the interdisciplinary team and the resident or their representative, which was not followed in this case.
Failure to Revise Care Plan with Resident Preferences
Penalty
Summary
The facility failed to ensure that comprehensive care plans were revised to reflect the preferences of a resident, which led to a deficiency. The resident, who was admitted with diagnoses including cerebral infarction, diabetes mellitus type-1, tracheostomy, and anoxic brain injury, was cognitively intact and had specific preferences documented in their care plan. These preferences included being addressed with they/them pronouns, appearing more masculine, and not wanting male caregivers. However, the care plan was not updated to reflect the resident's preference against male caregivers, which was only communicated to the facility by the resident's power of attorney after a male caregiver had already provided care. The Director of Nursing confirmed that the care plan had not been revised to include the resident's preference against male caregivers. This oversight occurred despite the facility being informed of the resident's preferences, and it was only after the notification from the power of attorney that male staff were removed from providing care to the resident. This deficiency was identified during an investigation under Complaint Number OH00156997.
Failure to Provide Ordered Tracheostomy Care
Penalty
Summary
The facility failed to ensure tracheotomy care was completed as ordered for two residents who were reviewed for tracheostomy care. Resident #64, who had diagnoses including cerebral infarction, epilepsy, and acute tracheitis, was admitted with orders for tracheostomy care every shift, along with weekly changes of aerosol, cool mist, and oxygen tubing. However, the treatment records indicated that tracheostomy care was not completed on several occasions, and equipment changes were missed. The care plan for Resident #64 did not include interventions for changing or cleaning equipment, despite the resident's partial ability to perform self-care. Similarly, Resident #75, with diagnoses including cerebral infarction, diabetes mellitus type-1, and anoxic brain injury, also had orders for tracheostomy care every shift and weekly equipment changes. The treatment records showed that these orders were not consistently followed, with missed tracheostomy care and equipment changes. The care plan for Resident #75 lacked interventions for cleaning equipment or daily care. The facility's policy required tracheostomy care to be provided according to physician's orders and professional standards, but this was not adhered to, as confirmed by the Director of Nursing.
Improper Gloving and Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to ensure proper gloving and hand washing during incontinence care for a resident diagnosed with dementia, obstructive and reflux uropathy, and functional incontinence. During an observation, a State tested Nurse Aide (STNA) and a Housekeeping Aide gathered supplies, washed their hands, and applied gloves before removing the resident's urine-soaked incontinence product. The STNA cleansed and rinsed the perineal area and buttocks but did not change gloves before adjusting the resident's gown, call light, and bed linens. The STNA then gathered soiled supplies, removed her gloves, and walked down the hallway to dispose of them without washing her hands before leaving the resident's room. During an interview, the STNA confirmed she had not changed her gloves or washed her hands, stating she hadn't given it a thought. The facility's policies on hand hygiene and perineal care require changing gloves if soiled and performing hand hygiene immediately after removing gloves, which were not followed in this instance.
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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 New Philadelphia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Park Village Hc Np Llc | 2.5 mi | — | 0 | 0 |
| Amberwood Manor | 3 mi | — | 0 | 0 |
| Country Club Center I | 4.7 mi | — | 20 | 1 |
| New Dawn Rehabilitation And Healthcare Center | 4.7 mi | — | 6 | 0 |
| Claymont Health And Rehabilitation | 4.7 mi | — | 2 | 0 |
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