Inspection Reports for Saint Margaret Hall
1960 Madison Rd, Cincinnati, OH 45206, United States, OH, 45206
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
6.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
37% worse than Ohio average
Ohio average: 4.6 deficiencies/year
Deficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
73 residents
Based on a January 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 4
Date: Jan 27, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to multiple complaints about the facility's failure to ensure phones were answered during nighttime hours, timely incontinence care, proper supervision during resident transfers, and maintaining satisfactory room temperatures.
Complaint Details
The deficiencies represent noncompliance investigated under Complaint Numbers OH 00161275 and OH 00161798.
Findings
The facility was found noncompliant in several areas including failure to answer phones during nighttime hours affecting resident communication, failure to provide timely incontinence care, inadequate supervision during mechanical lift transfers resulting in a resident fall, and failure to maintain comfortable room temperatures for residents.
Deficiencies (4)
Facility failed to ensure phones were answered during nighttime hours, affecting communication with Resident #45.
Facility failed to provide timely incontinence care to Resident #36, with delays exceeding the required two-hour interval.
Facility failed to provide appropriate supervision during resident transfers using a sit to stand lift, resulting in a fall of Resident #36.
Facility failed to ensure satisfactory temperature in resident rooms, with Resident #43's room temperature measured at 68 degrees Fahrenheit.
Report Facts
Facility census: 73
Room temperature: 68
Incontinence care interval: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #102 | Licensed Practical Nurse | Named in phone answering deficiency and terminated for safety violations |
| RN #105 | Registered Nurse | Supervisor who kept the facility phone on her person and answered calls during weekend |
| CNA #107 | Certified Nursing Assistant | Named in incontinence care deficiency |
| CNA #112 | Certified Nursing Assistant | Named in fall during mechanical lift transfer and terminated for violating facility policy |
| MM #100 | Maintenance Man | Named in room temperature deficiency for adjusting heater |
| DON | Director of Nursing | Provided multiple confirmations and interviews related to deficiencies |
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 1
Date: Nov 18, 2024
Visit Reason
The inspection was conducted due to complaints regarding improper use of lift equipment for resident transfers, specifically concerning Resident #10.
Complaint Details
This deficiency represents noncompliance investigated under Master Complaint number OH00159809 and Complaint Numbers OH00159808 and OH00159768.
Findings
The facility failed to use the proper Hoyer lift for transferring Resident #10, instead using a stand-up lift which caused bruising. Therapy had recommended use of the Hoyer lift with assistance of two staff for safety.
Deficiencies (1)
Failure to use the proper lift for resident transfers, resulting in bruising to Resident #10.
Report Facts
Residents affected: 1
Facility census: 81
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physical Therapy Manager #40 | Physical Therapy Manager | Confirmed therapy recommendation for use of Hoyer lift for Resident #10 |
| Director of Nursing | Director of Nursing | Confirmed staff used stand-up lift instead of Hoyer lift and noted resident's increased bruising risk due to blood thinning medication |
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 3
Date: Sep 30, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of inadequate care including failure to assist residents with activities of daily living, pressure ulcer care, repositioning, and bladder scanning.
Complaint Details
The deficiencies represent non-compliance investigated under Complaint Numbers OH00157615 and OH00157917.
Findings
The facility was found non-compliant for failing to provide timely assistance with activities of daily living to a resident, inadequate pressure ulcer care and repositioning for three residents, and failure to complete bladder scans and notify physicians as ordered for one resident. These deficiencies affected a few residents and were supported by medical record reviews, observations, and staff and family interviews.
Deficiencies (3)
Failed to ensure a resident dependent on staff for transfers received timely assistance with activities of daily living.
Failed to provide appropriate pressure ulcer care and prevent new ulcers from developing, including failure to turn and reposition residents every two to three hours and failure to complete wound treatments as ordered.
Failed to provide appropriate care for residents who are continent or incontinent of bowel/bladder, including failure to complete bladder scans as ordered and failure to notify physician of issues.
Report Facts
Facility census: 87
Residents affected: 1
Residents affected: 3
Residents affected: 1
Bladder scan readings: 543
Bladder scan readings: 511
Employees mentioned
| Name | Title | Context |
|---|---|---|
| STNA #227 | State Tested Nursing Aide | Named in finding for failure to assist Resident #3 with getting out of bed |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding wound care and bladder scan deficiencies |
| Licensed Practical Nurse #250 | Licensed Practical Nurse (LPN) | Interviewed regarding turning and repositioning residents #10 and #72 |
| STNA #170 | State Tested Nursing Aide | Interviewed regarding failure to turn and reposition residents #10 and #72 |
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 3
Date: May 16, 2024
Visit Reason
The inspection was conducted as a complaint investigation under Complaint Number OH00153089, focusing on medication administration errors, medication storage, infection prevention and control practices, and wound care procedures.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00153089.
Findings
The facility was found to have multiple deficiencies including failure to administer medications via the physician ordered route, improper medication storage without nurse supervision, failure to disinfect glucose monitoring devices between residents, and inadequate infection control practices during wound care. These deficiencies affected a few residents and posed minimal harm or potential for actual harm.
Deficiencies (3)
Failed to ensure medications were administered via the physician ordered route affecting one resident.
Failed to ensure medications were securely stored; medications left at bedside without nurse supervision affecting two residents.
Failed to disinfect glucose monitoring device after usage and failed to ensure hand hygiene after wound dressing removal affecting three residents.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 3
Facility census: 69
Facility census: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #113 | Registered Nurse | Verified medication left at bedside without nurse supervision and involved in wound care deficiency |
| LPN #92 | Licensed Practical Nurse | Observed failing to disinfect glucose monitoring device between residents |
| LPN #202 | Licensed Practical Nurse | Left medication at bedside for Resident #19 |
| DON | Director of Nursing | Notified about medication administration error and verified infection control practices |
| NP #600 | Nurse Practitioner | Observed during wound care procedure with deficiencies |
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 1
Date: Feb 29, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's infection prevention and control program, specifically related to water contamination risks.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00151428.
Findings
The facility failed to have a comprehensive water management plan to prevent water contamination, including monitoring disinfectant levels. Observations and interviews confirmed the lack of a formal plan despite some informal measures being taken. The facility responded by suspending water use, providing bottled water, installing filters, and contacting health authorities.
Deficiencies (1)
Failed to have a comprehensive water management plan to prevent water contamination, including monitoring disinfectant levels.
Report Facts
Census: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director #20 | Maintenance Director | Confirmed lack of comprehensive water management plan and described informal water safety measures |
| Director of Nursing | Director of Nursing (DON) | Described facility's response to possible legionella contamination including contacting health department and implementing safety measures |
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 3
Date: Feb 2, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on allegations of failure to treat residents with dignity and respect, failure to ensure access to call lights, and failure to provide timely incontinence care.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00149928 for dignity and respect issues, and Master Complaint Numbers OH00150176 for incontinence care issues.
Findings
The facility was found to have failed in treating a resident with dignity and respect, ensuring a resident had access to their call light, and providing timely incontinence care to two residents. These deficiencies affected a few residents and were supported by observations, interviews, and record reviews.
Deficiencies (3)
Failed to treat a resident with dignity and respect, including disrespectful behavior by staff.
Failed to ensure a resident had access to their call light.
Failed to provide timely incontinence care for two residents.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 2
Facility census: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| State Tested Nurse Aide (STNA) #115 | Named in dignity and respect finding for disrespectful behavior to Resident #28 | |
| Human Resource Director #97 | Documented disciplinary action related to STNA #115 | |
| Licensed Practical Nurse (LPN) #56 | Verified call light placement issue for Resident #71 | |
| Occupational Therapy Assistant (OTA) #725 | Provided incontinence care to Resident #328 | |
| Physical Therapy Assistant (PTA) #710 | Provided incontinence care to Resident #328 | |
| State Tested Nurse Aide (STNA) #117 | Failed to provide incontinence care for Resident #328 | |
| State Tested Nurse Aide (STNA) #50 | Checked and changed Resident #328 last at 9:32 A.M. | |
| State Tested Nurse Aide (STNA) #715 | Did not take care of Resident #328 |
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 10
Date: Feb 2, 2024
Visit Reason
The inspection was conducted as a complaint investigation triggered by allegations of dignity and respect violations, call light access issues, advance directive documentation problems, injury reporting failures, care plan deficiencies, hearing aid access issues, fall prevention concerns, incontinence care deficiencies, and medication supervision lapses.
Complaint Details
This inspection was conducted under Complaint Numbers OH00149928, OH00150176, and Master Complaint Number OH00150176. The complaints involved allegations of dignity and respect violations, call light accessibility issues, advance directive documentation, injury reporting and investigation failures, care planning deficiencies, hearing aid access, fall prevention, incontinence care, and medication supervision.
Findings
The facility was found to have multiple deficiencies including failure to treat a resident with dignity and respect, failure to ensure call light accessibility, incomplete documentation of advance directives, failure to timely report and investigate an injury of unknown origin, incomplete care planning for resident behaviors, failure to assist a resident with hearing aids, inadequate supervision to prevent falls, untimely incontinence care, and failure to supervise medication administration properly.
Deficiencies (10)
Failed to treat a resident with dignity and respect, including staff yelling and rushing care.
Failed to ensure a resident had access to their call light.
Failed to ensure advance directives were documented appropriately.
Failed to timely report an injury of unknown origin to the state agency.
Failed to thoroughly investigate an injury of unknown origin.
Failed to ensure resident care plans reflected current status and behaviors.
Failed to ensure a resident had access to hearing aids and did not have a care plan for refusal.
Failed to ensure residents received proper staff assistance to prevent falls.
Failed to provide timely incontinence care for residents.
Failed to provide supervision when taking medication for a resident.
Report Facts
Facility census: 72
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| STNA #115 | State Tested Nurse Aide | Named in dignity and respect deficiency for yelling and rushing care of Resident #28 |
| Human Resource Director #97 | Human Resource Director | Documented disciplinary action investigation for STNA #115 |
| LPN #56 | Licensed Practical Nurse | Verified call light placement and medication supervision issues |
| LPN #820 | Licensed Practical Nurse | Confirmed absence of completed DNR form for Resident #37 |
| Director of Nursing | Director of Nursing | Verified injury reporting and investigation failures for Resident #51 |
| Physician #850 | Physician | Determined Resident #51's shoulder dislocation was pathological due to osteoarthritis |
| LPN Unit Manager #900 | Licensed Practical Nurse Unit Manager | Verified care plan deficiencies for Residents #70 and #43 |
| STNA #830 | State Tested Nurse Aide | Witnessed fall incident for Resident #66 |
| LPN #102 | Licensed Practical Nurse | Witnessed fall incident and assisted Resident #66 |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jan 16, 2020
Visit Reason
Annual survey inspection of Carecore at Margaret Hall nursing home conducted to assess compliance with health regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Dec 6, 2018
Visit Reason
The document is an annual inspection report for Carecore at Margaret Hall, conducted to assess compliance with health regulations.
Findings
No health deficiencies were found during the inspection.
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