Inspection Reports for Mount Washington Care Center
6900 Beechmont Ave, Cincinnati, OH 45230, OH, 45230
Back to Facility ProfileInspection Report Summary
The most recent inspection on August 14, 2025, identified deficiencies related to the facility’s failure to implement physician orders for appropriate respiratory care for one resident. Earlier inspections showed a pattern of deficiencies involving resident care coordination, timely medical interventions, staffing, infection control, and documentation. Prior reports cited issues such as delayed physician notifications, inadequate fall investigations, insufficient incontinence care, and lapses in discharge planning and nursing coverage. Complaint investigations were mostly substantiated, with no fines or enforcement actions listed in the available reports. The facility’s inspection history shows ongoing challenges with care implementation and staff coordination, with no clear improvement trend evident.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
7.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
61% worse than Ohio average
Ohio average: 4.6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
70 residents
Based on a August 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 1
Date: Aug 14, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure implementation of physician orders for appropriate respiratory care for a resident.
Complaint Details
This deficiency represents noncompliance investigated under Complaint Number 2584605.
Findings
The facility failed to provide safe and appropriate respiratory care for Resident #71, who was admitted with a tracheostomy and respiratory issues but lacked physician orders for tracheostomy care or oxygen administration. Staff relied on nursing judgment, resulting in respiratory distress and hospital transfer.
Deficiencies (1)
Failure to ensure implementation of physician orders for appropriate respiratory care for Resident #71, including lack of orders for tracheostomy care and oxygen administration.
Report Facts
Oxygen saturation level: 68
Oxygen saturation level: 76
Oxygen flow rate: 4
Oxygen flow rate: 7
Residents reviewed for respiratory care: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #109 | Licensed Practical Nurse | Confirmed administration of oxygen and reliance on nursing judgment for Resident #71's respiratory care |
| Director of Nursing | Director of Nursing | Confirmed lack of physician orders and reliance on nursing judgment for Resident #71's respiratory care |
Inspection Report
Routine
Census: 80
Deficiencies: 11
Date: Feb 26, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident rights, notification procedures, care planning, treatment and care, medication management, infection control, and food safety.
Findings
The facility was found deficient in multiple areas including timely meal service to dependent residents, failure to notify Ombudsman of resident transfers, inadequate care conferences, failure to implement pressure ulcer prevention interventions, improper use of mechanical lift slings, lack of safe smoking evaluations, inadequate hydration and nutrition monitoring, ineffective pain management after a fall, improper insulin labeling and storage, delayed dental care, unsanitary kitchen conditions, and failure to implement appropriate infection control measures.
Deficiencies (11)
Failed to serve meals to all residents in the dining room in a timely manner affecting dependent residents.
Failed to notify the Ombudsman when residents were transferred or discharged from the facility.
Failed to ensure care conferences were held quarterly as required for residents and their representatives.
Failed to ensure residents at risk for skin breakdown had interventions implemented to prevent skin breakdown.
Failed to utilize the correct transfer lifting sling for the mechanical lift and failed to properly assess residents for safe smoking practices.
Failed to provide adequate hydration and monitor weight changes, notify physician, and implement interventions for residents at nutritional risk.
Failed to effectively manage pain for a resident following an unwitnessed fall resulting in a femoral neck fracture.
Failed to ensure insulin vials were properly labeled with opened dates and stored according to policy.
Failed to provide timely dental care services to a resident requesting denture repair.
Failed to maintain a sanitary kitchen to prevent cross contamination of food and failed to follow proper food handling and hygiene practices.
Failed to provide appropriate infection control measures during incontinence care and failed to implement enhanced barrier precautions for a resident with a multi-drug resistant organism.
Report Facts
Residents affected: 2
Residents affected: 7
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 4
Residents affected: 1
Residents affected: 78
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #195 | Certified Nursing Assistant | Named in meal service delay finding |
| CNA #178 | Certified Nursing Assistant | Named in meal tray misrouting and delay finding |
| RD #300 | Registered Dietitian | Named in meal service delay finding |
| SSD #106 | Social Services Director | Named in Ombudsman notification and care conference findings |
| LPN #177 | Licensed Practical Nurse | Named in pressure ulcer prevention finding |
| LPN #126 | Licensed Practical Nurse | Named in pressure ulcer prevention finding |
| CNA #103 | Certified Nursing Assistant | Named in infection control and pain management findings |
| CNA #148 | Certified Nursing Assistant | Named in pain management finding |
| DON | Director of Nursing | Named in multiple findings including pressure ulcer prevention, mechanical lift sling use, pain management, nutrition, and infection control |
| RD #695 | Registered Dietitian | Named in nutrition and food safety findings |
| LPN #55 | Licensed Practical Nurse | Named in insulin labeling and storage finding |
| LPN #155 | Licensed Practical Nurse | Named in insulin labeling and storage finding |
| Consulting Pharmacist #199 | Pharmacist | Named in insulin labeling and storage finding |
| LPN #104 | Licensed Practical Nurse | Named in dental care finding |
| SSD #106 | Social Services Designee | Named in dental care finding |
| [NAME] #180 | Food Service Worker | Named in food safety and sanitation findings |
| [NAME] #150 | Diet Aide | Named in food safety and sanitation findings |
| Diet Aid #135 | Diet Aide | Named in food safety and sanitation findings |
| RN #181 | Registered Nurse | Named in infection control finding |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 129
Deficiencies: 4
Date: Jan 5, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on multiple complaints regarding failure to timely notify physicians of changes in resident conditions, failure to investigate resident falls, failure to provide timely incontinence care, and failure to have a full-time qualified social worker.
Complaint Details
This inspection was conducted under Complaint Numbers OH00148872, OH00149067, OH00149419, and OH00148872. The complaints involved failure to notify physicians of changes in condition, failure to investigate falls, failure to provide incontinence care, and staffing deficiencies.
Findings
The facility was found non-compliant in several areas including failure to timely notify the physician of abnormal vital signs for Resident #78, failure to investigate resident falls and determine root causes for three residents (#25, #82, #86), failure to provide timely incontinence care for Resident #80, and failure to employ a full-time qualified social worker for a facility with more than 120 beds.
Deficiencies (4)
Failed to timely notify the physician when Resident #78 had abnormal vital signs during a change in condition and infection treatment.
Failed to investigate resident falls and determine root cause for residents #25, #82, and #86.
Failed to provide timely incontinence care for Resident #80, resulting in skin redness and incontinence associated dermatitis.
Failed to have a full-time qualified social worker for a facility with more than 120 beds.
Report Facts
Facility census: 82
Total licensed capacity: 129
Fall risk score: 16
Fall risk score: 14
Fall risk score: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medical Director #440 | Medical Director | Interviewed regarding failure to be notified of Resident #78's abnormal vital signs |
| Unit Manager #225 | Unit Manager | Documented progress notes and involved in notification process for Resident #78 |
| Licensed Practical Nurse #227 | Licensed Practical Nurse | Verified Resident #80's skin condition and involved in care observations |
| Director of Nursing | Director of Nursing | Interviewed regarding fall investigations and staffing |
| Wound Nurse Practitioner #311 | Wound Nurse Practitioner | Assessed Resident #80 for skin issues and ordered treatment |
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 2
Date: Oct 16, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to discharge planning and staffing concerns at the facility.
Complaint Details
The deficiencies represent non-compliance investigated under Complaint Numbers OH00147320 (discharge planning) and OH00147089 (staffing).
Findings
The facility failed to coordinate care with the home health agency to ensure a smooth and safe resident discharge for one resident, and failed to ensure a Registered Nurse was working at least 8 hours on one day, potentially affecting all residents.
Deficiencies (2)
Failed to coordinate care with the home health agency to ensure a smooth and safe resident discharge for Resident #90.
Failed to ensure a Registered Nurse was working at least 8 hours on 10/14/23.
Report Facts
Residents affected: 1
Census: 89
Residents affected: 89
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #123 | Registered Nurse | Named in discharge planning deficiency related to failure to notify home health agency and incomplete discharge paperwork |
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 1
Date: Feb 8, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to obtain a timely urinalysis for a resident with a urinary tract infection.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00138987.
Findings
The facility failed to obtain a urinalysis in a timely manner for Resident #90, resulting in delayed diagnosis and treatment of a urinary tract infection. The urinalysis was ordered on 01/04/23 but not collected until 01/12/23, and results were not reported to the physician until 01/17/23, delaying antibiotic treatment until 01/18/23.
Deficiencies (1)
Failure to obtain a urinalysis in a timely manner resulting in delayed care for a resident with a urinary tract infection.
Report Facts
Facility census: 78
Resident reviewed for change in condition: 3
Resident #90 admission date: Admission date 09/01/22 (date not numeric)
Urinalysis ordered date: 01/04/23 (date not numeric)
Urinalysis collection date: 01/12/23 (date not numeric)
Lab work date: 01/15/23 (date not numeric)
Physician notified date: 01/17/23 (date not numeric)
Antibiotic start date: 01/18/23 (date not numeric)
Antibiotic dosage: 875
Antibiotic dosage: 125
Antibiotic duration: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Interview confirmed delay in obtaining urinalysis and reporting results |
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 1
Date: Feb 8, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to obtain a timely urinalysis for a resident with a urinary tract infection.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00138987.
Findings
The facility failed to obtain a urinalysis in a timely manner for Resident #90, resulting in delayed diagnosis and treatment of a urinary tract infection. The urinalysis was ordered on 01/04/23 but not collected until 01/12/23, and results were not reported to the physician until 01/17/23, delaying antibiotic treatment until 01/18/23.
Deficiencies (1)
Failure to obtain a urinalysis in a timely manner resulting in delayed care for a resident with a urinary tract infection.
Report Facts
Facility census: 78
Resident reviewed for change in condition: 3
Resident #90 admission date: Sep 1, 2022
BIMS score: 15
Urinalysis ordered date: Jan 4, 2023
Urinalysis collection date: Jan 12, 2023
Lab work date: Jan 15, 2023
Physician notified date: Jan 17, 2023
Antibiotic start date: Jan 18, 2023
Antibiotic dosage: 875
Antibiotic dosage: 125
Antibiotic duration: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Confirmed delay in obtaining urinalysis and reporting results to physician |
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 14
Date: Feb 4, 2022
Visit Reason
The inspection was conducted based on complaints and allegations regarding resident care, medication administration, facility cleanliness, and regulatory compliance.
Complaint Details
The deficiencies substantiate multiple complaint numbers including OH00129093, OH00129099, OH00110816, and Master Complaint Number OH00129592.
Findings
The facility was found deficient in multiple areas including failure to provide appropriate clothing, inaccurate advance directives, unclean resident rooms, lack of PASRR screening, failure to develop baseline care plans, inadequate assistance with activities of daily living, improper use of splints and palm protectors, incorrect IV catheter placement, failure to monitor psychotropic medication side effects, improper medication storage, failure to provide therapeutic diets and food preferences, and failure to maintain proper refrigerator temperatures.
Deficiencies (14)
Failed to ensure residents had appropriate clothing to wear.
Failed to ensure resident advance directives were accurate.
Failed to maintain resident room environment in a clean, sanitary and comfortable manner.
Failed to ensure a valid Pre-admission Screen and Resident Review (PASRR) was in place.
Failed to develop a baseline care plan for residents within 48 hours of admission.
Failed to provide care and assistance to perform activities of daily living for residents who are unable.
Failed to ensure residents received specialized range of motion appliances as ordered by the physician.
Failed to ensure an intravenous (IV) catheter was initiated on the correct resident.
Failed to monitor for adverse side effects for residents receiving psychotropic medications.
Failed to ensure residents receiving as needed psychotropic medications was limited to 14 days and not continued without physician evaluation.
Failed to ensure medications were safely stored and labeled in accordance with professional standards.
Failed to ensure staff was available to assist dependent residents with eating after meals trays were delivered.
Failed to provide each resident with a therapeutic diet as ordered by their physician.
Failed to ensure refrigerator temperatures were checked routinely and residents' refrigerated foods were properly labeled.
Report Facts
Facility census: 84
Deficiencies cited: 14
Resident weight: 156.4
Resident weight: 156.8
Resident weight: 156.5
Resident weight: 148.1
Medication administration dates: 5
Medication administration dates: 1
Medication doses: 0.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #123 | Licensed Practical Nurse | Verified Resident #434 was wearing a hospital gown |
| Licensed Practical Nurse #118 | Licensed Practical Nurse | Confirmed discrepancy regarding Resident #02's code status |
| Housekeeper #26 | Housekeeper | Verified rooms of Residents #07, #25, and #48 were not clean |
| Housekeeper #21 | Housekeeper | Reported facility was short staffed and had not started cleaning assigned rooms |
| Housekeeping and Laundry Supervisor #07 | Housekeeping and Laundry Supervisor | Verified rooms of Residents #25 and #48 were dirty |
| Social Services Director #04 | Social Services Director | Confirmed PASRR was not requested for Resident #382 |
| Minimum Data Set Nurse #11 | Minimum Data Set Nurse | Confirmed failure to implement baseline care plans for Residents #68 and #382 |
| Assistant Director of Nursing #09 | Assistant Director of Nursing | Reported Resident #48 was scheduled for showers on Tuesdays and Fridays and verified IV incident |
| Licensed Practical Nurse #130 | Licensed Practical Nurse | Last administered medication to Resident #37 on 01/26/22 |
| Agency STNA #131 | State Tested Nursing Assistant | Verified Resident #37 and #43 did not have splints or palm protectors in place |
| Director of Nursing | Director of Nursing | Verified Resident #09 required assistance with eating and confirmed IV incident |
| Registered Nurse #79 | Registered Nurse | Started IV on wrong resident #50 |
| Licensed Practical Nurse #130 | Licensed Practical Nurse | Verified Resident #58 should not have medications in room |
| Licensed Practical Nurse #69 | Licensed Practical Nurse | Confirmed pills left at bedside of Resident #70 |
| State Tested Nursing Assistant #85 | State Tested Nursing Assistant | Reported Resident #15 was supposed to have hot chocolate with every meal |
| Diet Technician #86 | Diet Technician | Verified standing orders and dietary error for Resident #54 |
| Registered Dietician #129 | Registered Dietician | Verified food temperatures were too low for Resident #36 |
Inspection Report
Annual Inspection
Census: 123
Deficiencies: 3
Date: Apr 18, 2019
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements related to resident rights, care planning, and accident prevention.
Findings
The facility was found deficient in ensuring accurate documentation of residents' advance directives and in implementing care plans to prevent potential elopement. Specifically, discrepancies were found in Resident #107's advance directive documentation, and Resident #20's care plan to prevent elopement was not fully implemented, including improper use and checking of a wander guard device.
Deficiencies (3)
Failed to ensure accurate and consistent documentation of Resident #107's advance directive across medical records.
Failed to implement Resident #20's care plan to prevent potential elopement, including inadequate supervision and improper checking of wander guard device.
Failed to ensure nursing home area was free from accident hazards and provided adequate supervision to prevent accidents related to Resident #20's elopement risk.
Report Facts
Residents reviewed for Advanced Directives: 24
Residents affected: 1
Facility census: 123
Residents reviewed for Accidents: 2
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #42 | Unit Manager, Registered Nurse | Interviewed regarding Resident #107's advance directive discrepancy and removal of DNRCC paperwork |
| RN #46 | Registered Nurse | Documented Resident #20's elopement risk assessment and application of wander guard device |
| LPN #22 | Licensed Practical Nurse | Interviewed and observed regarding checking and functioning of Resident #20's wander guard device |
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