Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
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 Twin Towers during CMS and state inspections, most recent first.
The facility failed to ensure proper food safety practices, affecting 72 residents. A staff member with a beard was observed preparing food without a beard cover, contrary to facility policy. Additionally, frozen foods were improperly stored, with items left open to air in the freezer. The Dietary Manager confirmed these practices were against the facility's policies.
The facility failed to conduct fit testing for respirators required for staff working with COVID-19 positive residents. An STNA was observed exiting a COVID-19 positive resident's room without the proper N95 respirator, and interviews revealed that other staff, including LPNs, had not been fit tested. The facility's policy requires fit testing upon hire and annually, but no records were available due to staff turnover and administrative changes.
A facility failed to notify a physician about a resident's bleeding during urinary catheter changes over several months. Despite the resident's history of prostate issues and moderate cognitive impairment, the LPN did not inform the physician of the bleeding incidents, which were documented multiple times. The facility's policy mandates notifying the physician of such health status changes, but this was not adhered to.
A resident with moderate cognitive impairment and a history of urinary issues had a physician's order for a specific catheter size, which was not followed by an LPN during a catheter change. The LPN used a larger balloon size due to unavailability of the correct size, causing the resident discomfort and hematuria. The DON and Administrator expected adherence to physician orders, and the physician was not informed of the deviation.
A resident with a history of urinary issues received inappropriate catheter care due to a nurse using a larger balloon size than ordered, causing discomfort and hematuria. The facility lacked regular nursing competencies and relied on computer-based education, contributing to the deficiency.
The facility failed to implement pharmacy recommendations for two residents regarding unnecessary medications. One resident continued to receive antipsychotic and antidepressant medications without a stop date, despite the physician agreeing to discontinue them. Another resident was given an antipsychotic without an allowable diagnosis, and the pharmacist's request for a diagnosis went unanswered. Staff interviews revealed that pharmacy recommendations were not consistently followed.
A survey revealed a medication error rate of 16.13% in an LTC facility, involving two residents. Errors included administering incorrect supplements and medications, such as Azo-Cranberry instead of cranberry concentrate and ferrous sulfate instead of ferrous gluconate. The RN acknowledged the errors, and the pharmacist confirmed the discrepancies. The facility's policy on medication administration was not followed.
Food Safety Violations in Kitchen
Penalty
Summary
The facility failed to ensure proper food safety practices in the kitchen, which had the potential to affect all 72 residents receiving meals. During an observation, a staff member with a full beard was seen preparing food without a beard cover. The staff member admitted to not knowing the requirement for wearing a beard cover, and the Dietary Manager confirmed that a beard cover should have been worn. The facility's policy, revised in January 2024, mandates that all facial hair be restrained with a beard net or restraint when working with food. Additionally, the facility did not properly store frozen foods. During an observation, a hamburger patty and a box of chicken tenders were found left open to air in the freezer. The Dietary Manager acknowledged that the food should have been sealed to prevent contamination. The facility's policy on food storage, also revised in January 2024, requires that unused portions and open packages be covered, labeled, and dated, and that food in frozen storage be wrapped tightly to prevent cross-contamination.
Failure to Conduct Respirator Fit Testing for COVID-19 Protection
Penalty
Summary
The facility failed to ensure that staff were fit tested for respirators required for respiratory protection when working with COVID-19 positive residents. This deficiency was observed when a State tested Nurse Aide (STNA) was seen exiting a COVID-19 positive resident's room wearing a surgical mask and gloves, instead of the required N95 respirator. The STNA admitted to not being fit tested for a respirator, despite wearing an N95 mask over a surgical mask when entering the room. Interviews with other staff members, including Licensed Practical Nurses (LPNs), revealed that they also had not been fit tested for respirators. The facility's Administrator and Director of Nursing (DON) acknowledged the lack of fit testing records, attributing it to staff turnover and changes in administration. The facility's policy on respiratory protection, which mandates fit testing upon hire and annually, was not adhered to, as no records could be provided. The policy also requires maintaining fit testing records for at least six years, which the facility failed to do, potentially affecting all 72 residents in the facility.
Failure to Notify Physician of Bleeding During Catheter Changes
Penalty
Summary
The facility failed to notify the physician regarding bleeding incidents during indwelling urinary catheter changes for a resident with a history of benign prostatic hyperplasia and obstructive and reflux uropathy. The resident, who had moderate cognitive impairment, experienced multiple instances of bleeding during catheter changes over several months. Despite the presence of blood in the urine and small blood clots during these procedures, there was no documentation indicating that the physician was informed of these occurrences. The Licensed Practical Nurse (LPN) responsible for changing the resident's catheter regularly acknowledged that the resident bled during these changes due to prostate issues but did not notify the physician. The physician confirmed that they were unaware of the bleeding incidents. The facility's policy requires notifying the resident, their physician, and a representative of any changes in health status, but this protocol was not followed in this case.
Failure to Follow Physician Orders for Catheter Care
Penalty
Summary
The facility failed to ensure staff followed physician orders for indwelling urinary catheter care for a resident with a history of benign prostatic hyperplasia and obstructive uropathy. The resident, who had moderate cognitive impairment, had a physician's order for a #18 French size catheter with a 10 mL balloon to be changed monthly and as needed. However, during a catheter change, an LPN used a #18 Fr catheter with a 30 mL balloon instead, citing the unavailability of the correct size. This deviation from the physician's order resulted in the resident experiencing discomfort and hematuria during the procedure. The Director of Nursing and the Administrator both expressed that the expectation was for nurses to follow physician orders exactly as written. The DON noted that there was a stock supply of items on site that should have been used, and the LPN could have contacted the physician to delay the catheter change until the correct size was available. The physician was not informed of the use of a larger catheter balloon or the bleeding that occurred, and he emphasized that catheter sizes should not be changed for staff convenience. The facility's catheter care policy indicated that residents with indwelling catheters should receive care to maintain hygiene and prevent complications such as urinary tract infections.
Inadequate Nursing Competency in Catheter Care
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies to provide appropriate care for a resident with an indwelling urinary catheter. Resident #49, who had a medical history of benign prostatic hyperplasia and obstructive uropathy, was admitted with an indwelling urinary catheter. The physician's order specified the use of a #18 French size catheter with a 10 mL balloon. However, during a catheter change, LPN #1 used a #18 French size catheter with a 30 mL balloon, which was not in accordance with the physician's order. This resulted in the resident experiencing discomfort and hematuria during the procedure. The Director of Nursing (DON) acknowledged that the facility did not conduct regular nursing competencies or in-services on indwelling urinary catheter care. The DON also confirmed that there was no policy for staff competencies, and the facility relied mostly on computer-based education. The lack of proper training and adherence to physician orders led to the inappropriate catheter care provided to Resident #49, highlighting a deficiency in ensuring nursing staff had the appropriate skills and competencies.
Failure to Implement Pharmacy Recommendations for Unnecessary Medications
Penalty
Summary
The facility failed to implement pharmacy recommendations for two residents regarding unnecessary medications. Resident #58, who was admitted with a history of Alzheimer's disease and dementia, was receiving antipsychotic and antidepressant medications. The pharmacist recommended discontinuing melatonin and olanzapine, but the physician's orders did not reflect a stop date for these medications. Despite the physician agreeing with the recommendation, the medications continued without documented psychiatric notes to justify their use. Resident #72, admitted with Alzheimer's disease, depression, and cognitive communication deficit, was also receiving antipsychotic and antidepressant medications. The pharmacist noted that the resident was receiving an antipsychotic without an allowable diagnosis and requested a diagnosis from the physician. However, there was no response to this request, and the antipsychotic medication continued to be administered for depression, which is not an approved singular treatment. Interviews with facility staff, including the Director of Nursing and the Assistant Director of Nursing, revealed that while pharmacy recommendations were communicated to physicians, the expectation for these recommendations to be followed was not met. The pharmacist confirmed that he performed drug regimen reviews and requested necessary diagnoses, but did not receive responses, leading to continued medication administration without appropriate justification.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 16.13% during a survey. This was identified through observations, staff interviews, medical record reviews, and facility policy reviews. The errors involved two residents, one with chronic kidney disease and urinary tract infections, and another with heart failure, hypertension, and mild cognitive impairment. The errors were observed during medication administration by a registered nurse. For the first resident, the nurse administered Azo-Cranberry instead of the prescribed cranberry concentrate 500 mg. The Azo-Cranberry contained additional ingredients not present in the prescribed supplement. The nurse acknowledged the error during an interview, and the pharmacist confirmed that the two products were not equivalent, highlighting the need for clarification before administration. For the second resident, the nurse administered incorrect medications, including calcium with vitamin D3, ferrous sulfate instead of ferrous gluconate, non-extended release vitamin C, and a multivitamin without the specified B complex. The nurse admitted to the errors, citing confusion with the electronic medication administration record. The pharmacist confirmed these as medication errors, noting differences in medication effects and types. The facility's policy emphasized the importance of following the five rights of medication administration, which were not adhered to in these instances.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Cincinnati
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ohio Living Llanfair | 0.7 mi | — | 4 | 0 |
| Mt Airy Gardens Rehabilitation And Nursing Center | 1.6 mi | — | 2 | 0 |
| Lakeridge Villa Health Care Center | 2.3 mi | — | 0 | 0 |
| Clovernook Health Care And Rehabilitation Center | 2.4 mi | — | 16 | 0 |
| Scarlet Oaks Nursing And Rehabilitation Center | 2.4 mi | — | 0 | 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 August 2026) and official state health department websites.