Astoria Place of Cincinnati

In the surveyor’s words

From the most serious findings on record at Astoria Place of Cincinnati, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Aug 17, 2026

  Based on record review, review of hospital records, review of emergency medical services (EMS) record, staff interviews, written staff statement reviews, observations, and policy reviews, the facility failed to ensure adequate supervision was in place to prevent a resident from climbing out a window on the second floor. This resulted in Immediate Jeopardy and serious physical harm and injuries on 07/22/26 when Resident #100 was found hanging from a windowpane and fell to the ground outside of the facility. Resident #100 had opened the window in room [ROOM NUMBER] and dropped two stories to the pavement below. The resident sustained a right temporal bone fracture, subdural and subarachnoid hemorrhage, epidural hematoma, sacral fracture and right clavicle fracture. […]

• Immediate jeopardy, isolatedF624May 19, 2025

  Based on resident interviews, staff interviews, an Ombudsman interview, police interviews, medical record review, and policy review, the facility failed to provide a safe discharge for Resident #19. This resulted in Immediate Jeopardy on 04/10/25 when Resident #19 was placed at risk for potential serious life-threatening harm, injuries, negative health outcomes and/or death when the facility discharged Resident #19 without providing a safe discharge location or provisions for a wound treatment. This affected one (Resident #19) of three residents reviewed for discharge. The facility census was 69. On 04/23/25 at 1:07 P.M., the Administrator, Director of Nursing (DON), and Regional Director of Operations (RDO) #200 were notified that Immediate Jeopardy began on 04/10/25 at 3:00 P.M. […]

• Immediate jeopardy, isolatedF689May 19, 2025

  Based on record review, review of hospital records, staff interviews, and policy review, the facility failed to ensure adequate supervision was in place to prevent one resident, identified as an elopement risk and who was assessed with purposeful exit seeking behaviors, from eloping from the facility unknown to staff. This resulted in Immediate Jeopardy and serious physical harm and injuries on 04/26/25 when Resident #75 was removed from one-on-one supervision and was subsequently found on the ground outside of the facility after removing a windowpane from the window in his room and dropping two stories to the pavement below, sustaining bilateral ankle fractures which required surgery. This affected one (Resident #75) of three residents reviewed for elopement risk. […]

• Immediate jeopardy, isolatedF689May 11, 2023

  Based on observation, record review, review of the Cincinnati Fire Department (CFD) first responders report, review of an Emergency Medical Services (EMS) report, review of the facility policy regarding elopement and interviews, the facility failed to provide adequate supervision to prevent Resident #10, who resided on and had physician orders (dated [DATE]) for placement on the facility's secured behavioral unit due to poor judgment and insight and safety concerns from eloping. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm/death on [DATE] at approximately 9:50 P.M. when Resident #10 exited the secured behavioral unit through an alarmed basement door without staff's knowledge. […]

• Immediate jeopardy, isolatedF677Apr 12, 2023

  Based on medical record review, review of hospital medical records, staff interview, and facility policy and procedure review, the facility failed to ensure a dependent resident (Resident #57) received adequate nail care. This resulted in Immediate Jeopardy on 03/08/23 when Resident #57 was found to have his fingernails grown into his palm, forming an abscess. Resident #57 was subsequently sent to the hospital and found to be severely septic (severe infection) and diagnosed with tenosynovitis (inflammation of a tendon) of the right middle finger and gas gangrene (highly lethal infection)/necrotizing fasciitis (a rare bacterial infection that spreads quickly in the body and can cause death) of the right middle finger. […]