Arc At Cincinnati
ARC AT CINCINNATI in CINCINNATI, OH — inspection on December 23, 2025.
Found 11 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During the meeting Resident #68 stated he knew diagnoses and medications of other residents and had been accused of, knowing too much; however, Resident #68 stated he knew these things due to overhearing the nurses and nurse aides talking. Resident #68 stated he had told staff it was a violation of the Health Insurance Portability and Accountability Act (HIPAA).
During the meeting, Resident #27 stated she also knew medical information about other residents, including some of the medications other residents were taking. Resident #27 further stated another resident (Resident #32) also heard information about other residents through her open door.Review of Resident #68's annual Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 11/13/25, revealed Resident #68 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition.
Review of Resident #27's quarterly MDS assessment, with an ARD of 10/01/25, revealed Resident #27 had a BIMS score of 15, which indicated the resident had intact cognition.
During an interview on 12/20/25 at 10:24 A.M., Resident #32 stated when staff gave report to one another, the resident was able to hear other residents' health information. Resident #32 further stated she knew what protected heath information included since she was a former nurse.
Review of Resident #32's quarterly MDS, with an ARD of 11/21/25, revealed Resident #32 had a BIMS score of 15, which indicated the resident had intact cognition.
Licensed Practical Nurse (LPN) #3 was interviewed on 12/20/25 at 1:19 P.M. and stated shift report was held at the nurses' station, and she was sure residents overheard protected health information. LPN #3 stated she knew it was a HIPAA violation all day long.
The Director of Nursing (DON) was interviewed on 12/21/25 at 10:28 A.M. and stated nurses completed shift report at the nurses' stations, but stated each nurses' station had an office area or a medication room that allowed the nurses to meet privately.
The DON stated she would not have expected the nurses to discuss residents' illnesses or medications where the information could be overheard by other residents.
The DON stated if other residents' information was overheard, it was a HIPAA violation.
The Administrator was interviewed on 12/21/25 at 3:46 P.M. and stated she expected staff to keep medical information about residents confidential.
Review of a facility policy titled, Dignity, revised 02/2021, indicated staff are to protect confidential clinical information.
Examples included verbal staff-to-staff communication (e.g. [exempli gratia, for example], change of shift reports) are conducted outside the hearing range of residents and the public.This deficiency represents non-compliance investigated under Complaint Number 2650678.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
365044 12/23/2025
Arc at Cincinnati 4001 Rosslyn Drive Cincinnati, OH 45209
on 12/19/25 at 10:12 A.M., LPN #09 stated they only worked at the facility as needed. LPN #09 stated they could not remember the specifics surrounding the incident involving Resident #97 but confirmed the resident was dependent on staff, requiring total assistance for all care.
During an interview on 12/19/25 at 10:32 A.M., the MDS/Care Plan Coordinator (MDS Coordinator) stated based on Resident #97's care plan and MDS, the resident was dependent on staff and required assistance from two staff for all care.
The MDS Coordinator stated she expected staff to follow the care planned interventions.
During an interview on 12/22/25 at 8:50 A.M., the Director of Nursing (DON) stated dependent care meant the resident was not able to participate in assisting with their care.
The DON stated Resident #97 required assistance from two staff for all care, and it was her expectation that all staff followed resident care planned interventions.
Review of the facility policy titled, Falls-Clinical Protocol, revised 03/2018, indicated Treatment/Management included, 1.
Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling.
This deficiency represents non-compliance investigated under Complaint Numbers 2614070.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/23/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Arc at Cincinnati
4001 Rosslyn Drive Cincinnati, OH 45209
SUMMARY STATEMENT OF DEFICIENCIES
facility shall help arrange transportation for residents as needed.
This deficiency represents non-compliance investigated under Complaint Number 2618734.
365044 12/23/2025
Arc at Cincinnati 4001 Rosslyn Drive Cincinnati, OH 45209
Review of Resident #45's Care Plan Report included a focus area, initiated
hematoma, craniotomy, medications, and depression. An observation of Resident #45's room on
was loose from the wall and left an approximate two-inch gap between the wall and the edge of the metal chair rail.
The observation revealed the metal chair rail had sharp edges extending from the lower edge and other areas of the wooden wainscoting were splintered, including an approximate two-inch splinter.
The Maintenance Director #55 was interviewed on [DATE] at 10:15 AM.
The Maintenance Director stated the danger of a board being loose from the wall or a splintered board in a resident's room would be access to electrical lines in the wall.
The Maintenance Director #55 stated he had not been notified about any splintered wood or loose boards in a resident's room.
The Maintenance Director #55 went to Resident #45's room and stated no one had reported the metal chair rail was loose from the wall and added that the edge was pointed and sharp.
The Maintenance Director #55 further stated no one had reported how rough the wood was in Resident #45's room or the large splinter sticking out from the wood.
The DON was interviewed on [DATE] at 9:57 A.M., and stated because the metal chair rail was loose in Resident #45's room, the resident could cut themself.
This deficiency represents non-compliance investigated under Complaint Numbers 2614070, 2621620, and 2618734.
365044 12/23/2025
Arc at Cincinnati 4001 Rosslyn Drive Cincinnati, OH 45209
During an interview on
checked it. If they were missing a medication, then they should check the emergency kit and if it was not available, then the nurse should notify the pharmacy so they could send it and call the provider if needed.
She stated if they did not get a resolution, then the nurse should call the DON.
She stated if the resident was taking a routine narcotic, an acceptable time for the resident to go without it would depend on the reason for the medication.
She stated she knew there were issues with getting Resident #39's methadone but she did not remember the details.
Review of the facility policy titled, Pain Assessment and Management, revised 04/2025, indicated Implementing Pain Management Strategies 6.
The medication regimen is implemented as ordered.
Results of the interventions are documented and communicated directly to the provider when appropriate.
Ongoing communication between the prescriber and the staff is necessary for the optimal and judicious use of pain medications.
The policy also specified, Monitoring and Modifying Approaches 4. If the resident is prescribed opioid analgesics, monitor for the following side effects: b.
Physical dependence which causes symptoms of withdrawal when opioid medication is stopped, or a dose is held or missed. 5.
Contact the provider immediately if the resident's pain or medication side effects are not adequately controlled.This deficiency represents non-compliance investigated under Complaint Number 2618734.
365044 12/23/2025
Arc at Cincinnati 4001 Rosslyn Drive Cincinnati, OH 45209
stage renal disease] facility include all aspects of how the resident ' s care will be managed,
Complaint Number 2618734.
365044 12/23/2025
Arc at Cincinnati 4001 Rosslyn Drive Cincinnati, OH 45209
specified (for example, before and after meal orders).This deficiency represents non-compliance
365044 12/23/2025
Arc at Cincinnati 4001 Rosslyn Drive Cincinnati, OH 45209
Based on observation, interview, and facility document and policy review, the facility failed to ensure
available to monitor the temperatures of one of two medication refrigerators and the facility failed to ensure staff monitored the temperatures of two of two medication refrigerators daily.
This had the potential to affect all residents residing on the [NAME] and Elm units.
The facility was census was
- An observation of the [NAME] Unit medication room on 12/16/2025 at 10:40 A.M. revealed 25
expired heparin lock flush solutions 50 United States Pharmacopoeia (USP) per 5 milliliters (ml); 12 had expiration dates of 07/2022, nine had expiration dates of 04/2023, and four had expiration dates of 03/2023.
All items were unopened but available for use during the observation.
Additional observation of the [NAME] Unit medication refrigerator on 12/16/2025 at 11:00 A.M. revealed there was no thermometer available to monitor the medication refrigerator temperatures.
The following medications were observed stored in the medication refrigerator: nine Lantus SoloStar 100 units/ml flex pens, nine insulin aspart 100 units/ml flex pens, four Bonsity (medication to treat osteoporosis) injection pens, three Trulicity (an injectable diabetic medication) 0.75 milligram (mg)/0.5 ml flex pens, and five Basaglar (a type of long-acting insulin) 100 units/ml flex pens. An observation of the medication cart located on the Elm Unit on 12/16/2025 at 11:25 AM revealed one house-stock tube of Solosite wound gel that expired on 09/01/2025, one enema saline laxative box that expired 11/2025, and one zinc oxide ointment 20 percent (%) that expired 10/2025.
Review of the 11/2025 Medication Refrigerator Temperature Log for the [NAME] Unit specified, to be documented every shift.
The log revealed the temperature was documented as checked on 11/08/2025 at 8:00 A.M. and 11/09/2025 at 9:00 A.M.
The 12/2025 Medication Refrigerator Temperature Log for the [NAME] Unit contained no documented temperature monitoring for the timeframe from 12/01/2025 through 12/15/2025.
The 11/2025 Medication Refrigerator Temperature Log for the Elm Unit revealed staff documented temperature monitoring on 11/01/2025 through 11/19/2025; however, the document revealed there was no documentation of temperature monitoring for the timeframe from 11/20/2025 through 11/30/2025.
The 12/2025 Medication Refrigerator Temperature Log for the Elm Unit revealed there was no documentation of temperature monitoring for the timeframe from 12/01/2025 through 12/15/2025 or 12/18/2025 through 12/23/2025.
During an interview on 12/16/2025 at 11:10 A.M., Licensed Practical Nurse (LPN) #1 stated the night shift was responsible for checking the medication refrigerators nightly to ensure the medication refrigerators contained a thermometer and to document the temperatures on the temperature logs.
She stated all nurses were responsible for monitoring for expired medications.
During an interview on 12/16/2025 at 3:55 P.M., the Director of Nursing (DON) stated the night shift nurses were responsible for checking the medication refrigerator temperatures and documenting on the logs each day.
She further stated each night, staff should check to ensure a thermometer was located inside the medication refrigerators.
The DON stated she was unsure whether staff were trained on who was responsible for checking the medication refrigerators and medication rooms for expired items.
During an interview on 12/18/2025 at 7:35 A.M., LPN #33 stated the responsibility to check the medication refrigerators had previously been a joint effort shared by the dayshift and nightshift nurses; however, she was recently notified that night shift nurses would be responsible for the monitoring.
Review of a facility policy titled, Medication Labeling and Storage, revised 02/2023, revealed , the facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls and the nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.
The policy continues to read, if the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.
365044 12/23/2025
Arc at Cincinnati 4001 Rosslyn Drive Cincinnati, OH 45209
the route of administration, the injection site (if applicable), any complaints or symptoms for which
investigated under Complaint Number 2650678.
365044 12/23/2025
Arc at Cincinnati 4001 Rosslyn Drive Cincinnati, OH 45209
During an interview on 12/19/25 at 1:26 P.M., Licensed Practical Nurse (LPN) #02 stated nebulizer equipment should be stored in a plastic bag when not in use.
She said there was not a plastic bag in the room, and she meant to get one to put the resident's nebulizer equipment in but got busy with something else and forgot.
During an interview on 12/23/25 at 9:24 A.M., the DON stated respiratory equipment should be covered when not in use.
She stated the nurses should have covered the nebulizer equipment and not set it on the table for infection control reasons.
During an interview on 12/23/25 at 10:44 A.M., the Administrator stated respiratory equipment should be stored in a bag when not in use, and she expected Resident #06's nebulizer equipment to be stored properly. 3.
Review of the medical record revealed the facility admitted Resident #37 on 06/19/23.
Diagnoses included chronic obstructive pulmonary disease (COPD), obstructive sleep apnea, and moderate persistent asthma.
Review of a quarterly MDS, with an ARD of 11/10/2025 revealed Resident #37 had a Brief Interview for Mental Status (BIMS) score of seven, which indicated the resident had severe cognitive impairment.
Review of Resident #37's Care Plan Report included a focus area initiated 07/05/24, indicating the resident had a history of altered respiratory status related to COPD, asthma, congestive heart failure (CHF), history of smoking, and obstructive sleep apnea, and use of a continuous positive airway pressureˆ(CPAP) machine. An observation on 12/15/25 at 12:01 P.M. , revealed Resident #37's CPAP mask was not stored in a plastic bag. An observation on 12/20/25 at 1:30 P.M. revealed Resident #37's CPAP mask was lying on the resident's dresser.
The mask was not stored in a plastic bag. An observation on 12/21/25 at 1:22 P.M. revealed Resident #37's CPAP mask was lying on the resident's dresser and the mask was not stored in a plastic bag.
During an interview on 12/21/25 at 1:30 P.M., CNA #29 verified he just placed CPAP masks on top of the dresser when they were not in use.
During an interview on 12/22/25 at 1:55 P.M.
CNA #31 verified CPAP masks were to be stored in a plastic bag when not in use.
During an interview on 12/21/2025 at 1:39 P.M., LPN # 10 stated CPAP masks should be stored inside a plastic bag when not in use.
During an interview on 12/22/25 at 6:10 P.M., the DON stated the facility did not have a policy for storage of CPAP masks.
The DON stated she expected staff to store CPAP masks in a plastic bag and not on top of a dresser or in a drawer.
During an interview on 12/21/25 at 2:54 P.M., the Administrator stated she expected staff to store CPAP masks in a bag when not in use.
365044 12/23/2025
Arc at Cincinnati 4001 Rosslyn Drive Cincinnati, OH 45209
During an interview on 12/22/2025 at 8:50 A.M., the Director of Nursing (DON) stated they expected all staff to attend and complete all required in-services.
The DON further stated that they expected the facility management team to monitor employee files to ensure compliance with the requirements.
During an interview on 12/22/2025 at 9:11 A.M., the Administrator stated they expected all staff to complete all required in-services and trainings.
During an interview on 12/22/2025 at 1:53 P.M., Human Resources Director (HRD) #61 revealed she was responsibility for ensuring all required employee trainings were completed. HRD #61 revealed the required abuse training for the four nurses were missing, and she could not explain why they were not completed. A facility policy titled, Abuse Prevention/Reporting Policy and Procedure, updated 05/09/2018, revealed abuse prevention procedures included training which indicated:1.
All new employees will receive training on the abuse policy.2.
All employees will attend training during orientation, mandatory annual training and more often as determined by the facility.3.
Training classes include at a minimum: a.
Definitions of abuse, neglect, exploitation, and misappropriation of resident property. b.
Reporting requirements regarding allegations of abuse, without fear of reprisals from any other individual whether they are staff, management, residents or visitors. c.
Appropriate interventions to deal with aggressive and catastrophic reactions to residents. d.
Recognition of and appropriate interventions for burnout, frustration and stress that could lead to reactions resulting in abusive situations.This deficiency represents non-compliance investigated under Complaint Number 2656167 and Complaint Number 2618734.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.