Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 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 Dayton Nursing And Rehabilitation during CMS and state inspections, most recent first.
Surveyors found that food preparation equipment, including baking sheets, muffin pans, steam table lids, and saucepans, had brown colored buildup on both inside and outside edges. Staff acknowledged ongoing efforts to clean the items, but the buildup remained. Facility policy and FDA guidelines require food-contact surfaces to be free of such accumulations, but these standards were not met.
The facility failed to maintain an infection prevention and control program by not documenting infection trends from July 2023 through July 2024. Interviews revealed that the previous DON allegedly deleted infection records, and the Regional MDS Nurse did not complete infection trending after assuming the role. This lack of documentation could risk cross-contamination and infection development among residents.
The facility failed to ensure accurate MDS assessments for two residents, leading to potential care risks. One resident was incorrectly assessed as receiving medications they were not taking, while another's tobacco use was not documented. These inaccuracies were due to oversight and system errors, as confirmed by staff interviews.
The facility failed to create comprehensive care plans for two residents, one with a wound and another receiving hospice services. A resident with hemiplegia did not have a care plan for a heel wound, despite physician orders for treatment. Another resident on hospice services lacked a care plan, which was acknowledged by the Corporate MDS Nurse. The Regional MDS Nurse and Administrator recognized the oversight, emphasizing the need for person-centered care plans.
A resident with deep vein thrombosis was prescribed Eliquis, but the facility failed to monitor for side effects of the anticoagulant. The absence of monitoring was confirmed through record reviews and staff interviews, revealing that the monitoring was overlooked when the order was entered into the system. The facility's policy required monitoring for complications, but this was not followed, posing a risk of bleeding.
The facility failed to secure venlafaxine, an antidepressant, which was left unattended at the nurses' station, accessible to staff, residents, and visitors. An LVN intended to return the medication to the pharmacy but left it unsecured. Interviews with the DON and Administrator confirmed that medications should not be left unattended, as per the facility's policy.
A resident with a full code status was found unresponsive, but an LVN failed to initiate CPR or call 911, mistakenly believing the resident's hospice status precluded resuscitation. This led to a delay of 2.5 hours before CPR was initiated, resulting in the resident being pronounced dead by EMS upon arrival.
The facility failed to provide appropriate pressure ulcer care for two residents, leading to the deterioration of their wounds. One resident's right dorsal foot wound worsened to an unstageable wound with eschar, requiring hospitalization for debridement and graft application. Another resident's blister on the right heel progressed to an unstageable wound with eschar due to inadequate monitoring and treatment. Staff interviews revealed inconsistencies in wound care practices and communication lapses.
A facility failed to provide appropriate care and coordinate with an orthopedic surgeon and attending NP/MD for a resident with a surgical wound and pressure injury. The lack of documentation and communication led to the deterioration of the resident's condition, requiring hospitalization and surgical intervention.
A resident returned from the hospital with a blister on her right heel, but the facility failed to notify the physician for treatment orders. The blister progressed to an unstageable wound with eschar, and weekly skin assessments were found to be incorrect. Interviews revealed that the facility's staff did not follow the protocol for notifying the physician, leading to a delay in treatment.
A facility failed to update a resident's care plan to include new pressure injuries, despite the resident's medical records and wound care consult indicating the presence and treatment of these injuries. Interviews with staff revealed that the oversight was due to a change in staff and a lack of adherence to the facility's care planning policy.
The facility failed to develop a comprehensive care plan within the required timeframe for a resident with significant medical conditions, including cardiac issues and hypertensive chronic kidney disease. The absence of a care plan from 02/02/2024 to 03/20/2024 was due to a change in staff and oversight, potentially placing the resident at risk of not receiving appropriate care.
A facility failed to maintain accurate medical records for a resident admitted with serious health conditions. The responsible LVN did not complete the initial admission assessment or document medications due to the resident's late arrival and subsequent medical emergency. The LVN was unable to return to complete the documentation due to illness.
Unsanitary Food Preparation Equipment in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to maintain sanitary conditions in the kitchen, specifically regarding the cleanliness of food preparation equipment. During an inspection, multiple items were found with brown colored buildup, including baking sheets, muffin pans, steam table lids, and saucepans. These items were observed to have buildup on both the inside and outside edges, and some were stacked together while still dirty. Staff interviews confirmed that efforts were being made to clean the equipment, but the buildup remained present at the time of the survey. A review of the facility's Sanitization Policy indicated that all equipment, food contact surfaces, and utensils are to be cleaned and sanitized using heat or chemical solutions. The FDA Food Code was also referenced, which requires food-contact surfaces of cooking equipment and pans to be free of encrusted grease deposits and other soil accumulations. Despite these policies, the facility did not ensure that the kitchen equipment was properly cleaned and sanitized, as evidenced by the observed buildup on multiple items.
Inadequate Infection Control Program Due to Lack of Trending
Penalty
Summary
The facility failed to maintain an infection prevention and control program, which is essential for providing a safe, sanitary, and comfortable environment for residents. The deficiency was identified through interviews and record reviews, revealing that the facility did not maintain a system for trending infections from July 2023 through July 2024. This lack of documentation and tracking could potentially place residents at risk of cross-contamination and the development of infections. Interviews with the facility's Administrator and the Regional MDS Nurse, who assumed the role of Infection Control Nurse, indicated that the previous Director of Nursing (DON) had left the facility in July 2024 and allegedly deleted the facility's computer records, including those related to infection trending. The Regional MDS Nurse admitted to not completing any infection trending after taking over the position. The facility's policy on infection surveillance, revised in September 2017, emphasized the importance of identifying individual cases and trends to guide appropriate interventions and prevent future infections. However, the absence of infection tracking and trending documentation highlighted a significant gap in the facility's infection control practices.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to potential risks in their care. Resident #4, a female with dementia, anxiety, and depression, was inaccurately assessed in the MDS as receiving anticoagulant and antidepressant medications, despite physician orders indicating otherwise. The resident had a history of depression but had not been on antidepressant medication since March 2024 and was only taking aspirin, which should not have been coded as an anticoagulant. Resident #12, a male with COPD, was inaccurately assessed in the MDS as not using tobacco, despite being a current everyday smoker. The resident's care plan and smoking risk assessment indicated he smoked every few hours and required supervision while smoking. Observations confirmed that the resident smoked daily and was monitored by staff during smoking times. Interviews with the Regional MDS nurse, DON, Administrator, and Regional Consultant revealed that the inaccuracies were due to oversight and system errors. The Regional MDS nurse acknowledged the errors and stated that the MDS assessments were not double-checked for accuracy, leading to misinformation about the residents' statuses. The facility's policy and the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual were not adhered to, resulting in the deficiencies.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, which included measurable objectives and timeframes to meet their medical, nursing, and psychosocial needs. Resident #2, an elderly female with hemiplegia and hemiparesis following a cerebral infarction, did not have a care plan for a trauma-induced wound on her right heel. Despite physician orders for daily wound care, the Treatment Nurse, who was responsible for writing care plans for new wounds, did not create one. The Regional MDS Nurse, who was the Treatment Nurse's supervisor at the time, acknowledged the oversight and admitted that it was his responsibility to ensure care plans were complete and accurate. Resident #3, an elderly male with a cerebral infarction due to embolism, was admitted to hospice services but did not have a corresponding care plan. The Corporate MDS Nurse, responsible for ensuring comprehensive care plans, confirmed the absence of a hospice care plan for Resident #3. The Administrator stated that every resident should have a person-centered care plan, and the Regional MDS Nurse was the interim DON when these care plans were not written. The facility's policy requires comprehensive person-centered care plans to be developed and implemented for each resident, describing the services needed to maintain their highest practicable well-being.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medication by not monitoring for side effects of the anticoagulant medication Eliquis. The resident, a male with a diagnosis of deep vein thrombosis, was prescribed Eliquis 5 mg twice daily. However, the facility did not document monitoring for side effects such as bleeding, which is crucial for patients on anticoagulant therapy. The absence of monitoring was confirmed through record reviews and interviews with staff, including the Assistant Director of Nursing (ADON) and the Director of Nursing (DON). The ADON acknowledged that the monitoring was overlooked and should have been included in the computer system when the order was entered. The DON, who was new to the position, confirmed that monitoring for side effects was not in place and emphasized the importance of such monitoring to prevent potential bleeding risks. The facility's policy on anticoagulant therapy required staff to monitor for complications and manage related problems, but this was not adhered to in the case of the resident.
Unsecured Medication at Nurses' Station
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, as required by their Medication Labeling and Storage policy. During an observation, two 30-count cards of venlafaxine, an antidepressant, were found left unattended on the desk at the nurses' station, accessible to staff, residents, and visitors. This incident occurred when an LVN left the medication out with the intention of returning it to the pharmacy but left the nurses' station without securing it. Interviews with the LVN, the DON, and the Administrator confirmed that medications should not be left unsecured and unattended, as they could be accessed by unauthorized individuals. The facility's policy clearly states that all medications and biologicals must be stored in locked compartments and that only authorized personnel should have access to them. The failure to adhere to this policy could lead to the misappropriation of property and drug diversion, posing a risk to residents.
Failure to Provide CPR to Full Code Resident
Penalty
Summary
The facility failed to provide basic life support, including CPR, to a resident who required emergency care, despite having physician orders and advance directives indicating a full code status. The incident involved a resident who was found unresponsive by a CNA at around 4:00 a.m. The CNA immediately notified an LVN, who failed to verify the resident's code status and instead called hospice. This led to a delay of approximately 2.5 hours before CPR was initiated, during which time the resident was pronounced dead by EMS upon their arrival. The resident, a male with diagnoses including cerebrovascular disease, pneumonia, and anoxic brain damage, had a care plan indicating a full code status. Despite this, the LVN did not initiate CPR or call 911, mistakenly believing that the resident's hospice status precluded the need for resuscitation. The LVN admitted to not checking the resident's code status and was more concerned with completing her other duties. The hospice nurse, upon arrival, informed the LVN that the resident was a full code, prompting the LVN to return to the facility and initiate CPR, but it was too late. Interviews with staff revealed that the facility had a system in place to identify residents' code statuses, including a binder on the crash cart and information in the computer. However, the LVN failed to utilize these resources. The facility's policy required CPR to be initiated unless a DNR order was present, which was not the case for this resident. The failure to provide timely CPR and call emergency services directly led to the resident not receiving potentially life-saving measures in a critical situation.
Removal Plan
- Immediate suspension of LVN A
- CPR audit conducted on all direct care staff
- Abuse/Neglect in-service
- In-service on emergency procedures for codes (CPR)
- Performed mock codes
- Held CPR training recertification class
Failure to Provide Appropriate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for two residents. For the first resident, the facility did not conduct proper assessments or provide necessary treatments for a pressure injury on the right dorsal foot, which deteriorated to an unstageable wound with eschar. Despite the resident's cognitive intactness and multiple diagnoses, including end-stage renal disease and a recent surgical procedure, the facility did not document or notify the physician about the worsening condition from 02/14/2024 to 02/27/2024. The resident eventually required hospitalization for wound irrigation, debridement, and graft application due to the severity of the wound and associated infection. Additionally, a pressure injury on the resident's right buttock was identified only upon hospital admission, indicating a lack of comprehensive skin assessments by the facility staff. For the second resident, the facility failed to monitor and treat a blister on the right heel, which was noted upon readmission. The blister deteriorated into an unstageable wound with eschar, but the facility did not document the changes or notify the physician in a timely manner. Weekly skin assessments from 02/23/2024 to 03/15/2024 did not reflect the presence of the blister, and there was no documentation of physician notification about the wound's progression. The resident's care plan and physician orders were not updated to address the worsening condition, leading to a delay in appropriate wound care and treatment. Interviews with facility staff, including LVNs, the DON, and the ADON, revealed inconsistencies in wound care practices and communication lapses regarding the residents' conditions. The facility's failure to adhere to professional standards of practice for pressure ulcer prevention and treatment resulted in significant deterioration of the residents' wounds, necessitating advanced medical interventions and hospitalizations.
Failure to Coordinate Care and Document Skin Condition
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for one resident reviewed for quality of care. The facility did not coordinate care with the orthopedic surgeon and attending NP/MD regarding a change in the resident's skin condition at the surgical area on the right lower extremity. This lack of coordination and communication led to the deterioration of the resident's pressure injury, which eventually required hospitalization, surgical debridement, and graft application. The resident, who had multiple diagnoses including a displaced trimalleolar fracture, osteomyelitis, and end-stage renal disease, was admitted to the facility with an external fixator on the right lower extremity. Despite the orthopedic surgeon identifying a scab and discolored skin on the resident's right foot, the facility did not document any assessment or treatment for this condition. Weekly skin assessments and other required documentation were either missing or incomplete, and there was no evidence of communication with the orthopedic surgeon or attending physician regarding the identified pressure injury. Interviews with facility staff revealed that the focus of care was primarily on the external fixator pin sites, and the dark or discolored area on the top of the resident's right foot was not adequately addressed. The facility's failure to follow up on outside appointments and obtain necessary documentation further contributed to the lack of appropriate care. The resident's condition worsened, leading to significant pain, infection, and the need for surgical intervention, highlighting the facility's deficiencies in care coordination and documentation.
Failure to Notify Physician of Change in Resident's Condition
Penalty
Summary
The facility failed to ensure the physician was consulted for a change of condition for a resident who returned from the hospital with a blister on her right heel. The resident, who had dementia and high blood pressure, was readmitted with a fracture of the femur. Despite the hospital discharge records noting the blister, the facility did not notify the physician for treatment orders upon the resident's return. Weekly skin assessments initially noted the blister but later failed to document it, and there was no record of the physician being notified of the blister's progression to an unstageable wound with eschar. Interviews with the DON, MD, NP, and ADON revealed that the facility's staff did not follow the protocol for notifying the physician of the change in the resident's condition. The MD and NP were unaware of the blister until much later, and the weekly skin assessments were found to be incorrect for several weeks. The facility's policy required prompt notification of changes in medical condition to the physician, but this was not adhered to, leading to a delay in treatment for the resident's wound.
Failure to Update Care Plan for New Pressure Injuries
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with new pressure injuries. The resident, a male with multiple diagnoses including anoxic brain damage, cerebrovascular disease, and sepsis, was identified with new pressure injuries on his buttocks. Despite the identification of these injuries and the subsequent orders for wound care, the resident's care plan was not updated to reflect these new needs. The resident's medical records indicated that he was moderately cognitively impaired and had triggered a care area assessment for pressure ulcers. However, the care plan dated after the identification of the new pressure injuries did not include these new issues. Nursing progress notes and a wound care consult confirmed the presence of the injuries and detailed the treatment plan, but this information was not incorporated into the resident's care plan. Interviews with the Assistant Director of Nursing (ADON) and the Administrator revealed that the care plan should have been updated to include the new pressure injuries. The ADON acknowledged that the care plan was not accurate and up-to-date, which could lead to staff being unaware of the resident's needs. The Administrator attributed the oversight to a change in staff and confirmed that the new MDS Coordinator and charge nurses were responsible for updating care plans. The facility's policy on care planning emphasized the importance of an interdisciplinary team in developing and updating care plans based on resident assessments.
Failure to Develop Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan within 7 days after the completion of the comprehensive assessment or no more than 21 days after admission for one of the residents reviewed. Specifically, Resident #3, who was admitted and readmitted on specified dates, did not have a comprehensive care plan from 02/02/2024 to 03/20/2024. The care plan should have been completed by 02/17/2024. Resident #3 had significant medical conditions, including cardiac issues, hypertensive chronic kidney disease, and a history of a fractured hip, which required careful monitoring and management. Despite these needs, the comprehensive care plan was not developed in the required timeframe, potentially placing the resident at risk of not receiving appropriate care and services. Observations and record reviews indicated that Resident #3 had 2+ edema in both lower extremities and episodes of asymptomatic hypotension. The resident's medical records showed that the cardiologist and attending nurse practitioner were aware of these conditions and had provided new orders. Interviews with the resident confirmed that she was aware of her cardiac issues and the efforts being made to manage her condition. However, the absence of a comprehensive care plan meant that these interventions were not formally documented and integrated into her care plan. Interviews with facility staff, including the ADON and the Administrator, revealed that the comprehensive care plan for Resident #3 was missed due to a change in staff. The previous MDS Coordinator, who was responsible for completing the care plans, had resigned, and the new MDS Coordinator had not completed the necessary documentation. The ADON acknowledged that the lack of a comprehensive care plan could lead to residents not receiving adequate care. The facility's policy required that a comprehensive, person-centered care plan be developed within seven days of the completion of the MDS assessment, but this was not adhered to in Resident #3's case.
Failure to Maintain Accurate Medical Records
Penalty
Summary
The facility failed to maintain accurate medical records for a resident admitted for rehabilitation services. The resident, who had multiple serious diagnoses including acute respiratory failure, pneumonia due to COVID-19, hypertension, myocardial infarction, and pulmonary embolism, was admitted to the facility but did not have an initial admission assessment completed by the assigned LVN. Additionally, there was no documentation on the Medication Administration Record (MAR) indicating what medications the resident was admitted with or whether any medications were administered during the resident's short stay at the facility. The LVN responsible for the resident's admission acknowledged that she did not complete the necessary documentation due to the resident arriving late in the evening and subsequently experiencing a medical emergency that required transfer back to the hospital. The LVN cited being overwhelmed with other emergencies and a high number of residents to care for as reasons for the incomplete documentation. She also mentioned that she became ill and was unable to return to the facility to finish the documentation. The facility's administrator confirmed that the documentation was incomplete and stated that the issue was addressed with the LVN over the phone. The facility's policy requires that all services provided to the resident, progress toward care plan goals, and any changes in the resident's condition be documented in the medical record. However, in this case, the required documentation was not completed, leading to a deficiency in maintaining accurate medical records for the resident.
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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 Dayton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Magnolia Place Health Care | 5.7 mi | — | 0 | 0 |
| Liberty Health Care Center | 5.8 mi | — | 4 | 2 |
| Focused Care At Cedar Bayou | 20.7 mi | — | 2 | 0 |
| Focused Care At Burnet Bay | 20.7 mi | — | 0 | 0 |
| Focused Care At Allenbrook | 20.8 mi | — | 3 | 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.