Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Silver Oaks Health Campus during CMS and state inspections, most recent first.
Call Light Not Kept Within Resident Reach: A resident with moderate cognitive impairment, heart failure, and a history of multiple falls was repeatedly observed with the call light out of reach, including on the floor behind a wheelchair and later hanging from a nightstand several feet away. An RN and the DON both confirmed the call light should have been positioned within reach, and the record noted the resident had recently been found on the floor by the recliner with a forehead abrasion after climbing over the recliner arm.
Failure to Notify Physician of Significant Weight Gain: Two residents with heart failure had significant daily weight increases documented without evidence that the physician was notified. One resident had gains of 4.3 pounds in 24 hours and 12.2 pounds in 48 hours, and another had a 10.1-pound gain in 24 hours despite an order requiring notification for smaller increases. Staff interviews confirmed the missing notifications and noted the EMAR had a place to document provider contact.
Improper Foley Catheter Drainage Bag Positioning: A resident with moderate cognitive impairment, obstructive uropathy, and total dependence for toileting hygiene and transfers had an indwelling urinary catheter drainage bag repeatedly observed hanging low enough to touch and drag on the floor while seated in a wheelchair and during transport. During one observation, the bag fell to the floor, was stepped on, and was picked up with bare hands before being reattached. An RN later stated the bag should not touch the floor, and the facility policy stated catheter tubing should not touch the floor to prevent infection.
Missing Meal Consumption Documentation: Meal intake was not documented for 3 residents reviewed for nutrition. One resident had severe cognitive impairment, malnutrition, and a G-tube, while two other residents were cognitively intact with diagnoses including femur fracture and HF. Multiple breakfast, lunch, and dinner entries were absent from the meal consumption records, and staff stated meals should be documented after each meal, but the Administrator reported no policy for documenting meal consumption.
Incomplete clinical records and medication order documentation were identified for two residents. A resident with a suprapubic catheter had no documented nursing assessments or catheter care orders beyond irrigation, even though staff stated catheter monitoring and site care should be documented in the EMAR/ETAR. Another resident receiving sertraline had orders for two different strengths, but the record lacked a specific order for the 50 mg dose, and the DON stated separate orders should have been present for both doses.
A resident with dementia and osteoporosis was given another resident’s evening medications when a QMA, distracted while using a medication cart for the first time, mixed up two cups of pills for residents in nearby rooms and failed to follow the facility’s five-rights medication policy. The resident, who was ordered cholesterol and dementia medications at bedtime, instead received another resident’s seizure and diabetic medications, and a family member also reported that staff had previously attempted to perform a blood sugar test on this non-diabetic resident that was intended for a different patient.
A resident with severe cognitive impairment and dependent on staff for care fell from bed during a dressing change, resulting in a tibia/fibula fracture. The fall occurred as the resident was on an air mattress without side rails, and staff were not present on both sides of the bed. The facility lacked a specific policy for turning residents, contributing to the incident.
A resident with quadriplegia sustained a second-degree burn on the left foot after a CNA, who was not trained in using a blow dryer for foot care, dried the resident's feet at the resident's request. The CNA was unaware that the resident could not feel her feet, leading to redness and blisters. The facility's policy on change in condition and the risks associated with heating appliances for residents with paralysis were not adequately addressed.
A resident was served a meal that did not comply with her prescribed mechanical soft diet. Despite the meal ticket indicating the correct diet, the resident received a regular diet meal. The error was confirmed by the RN, Speech Therapist, and Dietary Manager, highlighting a lapse in following dietary orders.
A resident did not receive the prescribed 2 mg dose of Coumadin from 04/26/24 through 04/28/24, despite physician orders. Interviews with nursing staff revealed a lack of clarity and communication regarding the medication orders, and the facility's medication administration policy was not followed.
The facility failed to provide adequate bathing for two dependent residents, who were severely cognitively impaired and had multiple diagnoses. Resident C received only 6 out of 20 scheduled showers or complete bed baths, while Resident D received only 7 out of 11 scheduled showers or complete bed baths. Staff interviews and record reviews revealed significant gaps in the provision and documentation of bathing, contrary to the facility's policies.
The facility failed to hold a resident's blood pressure medication when the heart rate was below the physician's hold parameters. Despite instructions to hold the medication if the heart rate was less than 60, the resident received the medication on multiple occasions when the heart rate was below this threshold.
The facility failed to identify and document a resident's pressure ulcers in a timely manner. The resident, who was at high risk for pressure ulcers, revealed sores on his bottom that were not present upon admission. Staff interviews indicated a lack of communication and awareness regarding the resident's wounds, and the facility's policy on skin observation was not followed.
Call Light Not Kept Within Resident Reach
Penalty
Summary
The facility failed to ensure call light accessibility for a resident with a history of frequent falls. The resident was observed seated in a recliner with the call light placed on the floor behind a wheelchair, about six feet away, and on another observation the call light was still in the same inaccessible location. During an interview, an RN observed the call light on the floor and stated it should be positioned within the resident's reach, acknowledging she had recently been in the room to obtain vital signs but had not noticed the call light was not accessible. On a later observation, the resident was again seated in the recliner with the call light hanging from the nightstand, approximately four feet away. The DON observed the call light on the nightstand and confirmed it should have been placed close enough for the resident to reach. The resident's record showed moderate cognitive impairment, diagnoses including heart failure, two or more falls without injury since the prior assessment, and assistance required for transfers between the chair and bed. An IDT note documented that the resident had been found on the floor by the recliner with an abrasion to the left forehead after climbing over the arm of the recliner.
Failure to Notify Physician of Significant Weight Gain
Penalty
Summary
The facility failed to notify the physician of residents’ changes in condition for 2 of 17 residents reviewed. Resident 76 had diagnoses including femur fracture and heart failure and was ordered to be weighed daily for congestive heart failure. The record showed a 4.3-pound weight gain in 24 hours and later a 12.2-pound weight gain in 48 hours, with no indication the physician was notified. During interview, an LPN stated that daily weights were documented in the EMAR and that staff would notify the physician by sending a message, and the DON stated she would have notified the physician of the resident’s weight gain. Resident 5 had a diagnosis of heart failure and a physician’s order for daily weights with notification required for a 3-pound gain in one day or a 5-pound gain in seven days. The record showed a 10.1-pound weight gain in 24 hours, with no indication the physician was notified and no documentation of notification in the EMAR. During interview, an RN stated the resident should have been reweighed to verify the significant weight change and the physician should have been notified. The facility policy stated the physician or practitioner should be aware of diagnostic testing results or any change in condition in a timely manner.
Improper Foley Catheter Drainage Bag Positioning
Penalty
Summary
The facility failed to ensure proper infection control practices were followed for the maintenance and positioning of an indwelling urinary catheter drainage bag for one resident. On 05/06/2026, the resident was observed sitting in a wheelchair with the urinary catheter drainage bag hanging beneath the chair and approximately two inches of the bag touching the floor. On 05/07/2026, the bag was again observed dragging on the floor during transport down the hall and later in a common area during a Resident Council meeting, with an estimated six inches of the bag touching the floor. During an observation and interview on 05/07/2026, the Activities Director transported the resident in the wheelchair when the drainage bag slipped from its secured position, fell to the floor, and was stepped on before being picked up with bare hands and reattached beneath the wheelchair. The Activities Director stated nursing staff should be notified whenever a drainage bag was observed touching the floor. Later that same morning, RN 2 stated the urinary catheter drainage bag should not be touching the floor and repositioned it. The resident’s record showed moderate cognitive impairment, obstructive uropathy, total assistance needed for toileting hygiene and transfers, and treatment with Cipro for a UTI in March 2026. The facility policy stated catheter tubing should not touch the floor to prevent infection.
Missing Meal Consumption Documentation
Penalty
Summary
The facility failed to document meal consumption for 3 of 3 residents reviewed for nutrition. Resident 4’s record showed severe cognitive impairment, a diagnosis of malnutrition, and a gastrostomy tube. A Registered Dietician progress note dated 05/08/2026 recommended discontinuing tube feedings and continuing a fortified diet with a nutritional pudding cup supplement three times a day, with reconsideration of tube feedings if weights and intakes declined. The Meal Consumption Record for Resident 4 lacked documented meal intake values on multiple dates for breakfast, lunch, and dinner. Resident 76’s admission MDS indicated the resident was cognitively intact and had diagnoses including femur fracture and heart failure. Resident 7’s quarterly MDS also indicated cognitive intactness, and the resident’s diagnosis included heart failure. For both residents, the Meal Consumption Record contained multiple missing meal intake entries across several dates and meals. During interview, a CNA stated that all resident meals should be documented after each meal and that refusals or times out of the facility should also be documented. The Administrator stated they did not have a policy for documenting resident meal consumptions.
Incomplete Clinical Records and Medication Order Documentation
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident with a suprapubic catheter. During interview and observation, the resident was noted to have catheter tubing extending from beneath her shirt to a drainage bag hanging beneath her wheelchair and reported she had recently completed antibiotic treatment for a UTI. The resident had diagnoses including reduced kidney function and neurogenic bladder, and the record showed an open-ended order to irrigate the suprapubic catheter with 250 mL of normal saline every Monday, Wednesday, and Friday. However, the clinical record contained no additional physician's orders related to catheter care or monitoring, including orders for insertion site assessment, catheter change frequency, or cleansing and dressing changes, and there was no routine nursing documentation for catheter assessments or care. RN 2 and RN 3 stated that catheter management, including monitoring the insertion site and cleansing and replacing the drain sponge, should be documented in the EMAR/ETAR, and the DON stated indwelling catheter care and monitoring should be documented there as well. The Administrator stated the facility did not have a policy regarding clinical record documentation or requirements for accurate and complete resident records. The facility also failed to ensure accurate documentation of medication administration for a resident receiving sertraline. The resident had a diagnosis of depression and was moderately cognitively impaired. One physician's order directed sertraline 50 mg, 1.5 tablets once daily through a specified end date, and a separate open-ended order directed sertraline 25 mg to be given along with the 50 mg dose for a total of 75 mg. The record lacked a specific physician's order for the 50 mg sertraline dose. During interview, RN 2 was unsure whether two different strengths required two separate physician orders, and the DON stated that if a resident had two different doses of sertraline, there should have been two separate physician orders so the nurse would document both doses. The facility policy titled Medication Orders stated medications are administered only upon the clear, complete, and signed order of an authorized prescriber.
Wrong-Resident Medication Administration Due to Failure to Follow Five Rights
Penalty
Summary
The deficiency involves a failure to follow the facility’s medication administration guidelines, specifically the five rights of medication administration, resulting in a resident receiving another resident’s medications. A family member reported that while visiting Resident D, a staff member attempted to perform a blood sugar test related to insulin use, even though Resident D was not diabetic and had never been on insulin; the family member stopped the staff member from performing the test. Later, the same family member was notified that Resident D had received the wrong medications. Resident D’s clinical record showed moderate cognitive impairment with diagnoses including osteoporosis and dementia, and the EMAR indicated that at the 9:00 P.M. medication pass the resident was to receive atorvastatin, donepezil, and Zetia. During an interview, QMA 2 stated that on the night in question she was using the 200 Hall medication cart for the first time and was distracted by another resident talking to her while at the cart. She had two cups of pills prepared, one with two medications and one with three medications, for residents in nearby rooms, Resident D and Resident E. After administering medications to Resident D, she realized at the cart that she had given Resident D Resident E’s 9:00 P.M. medications instead of Resident D’s ordered medications. Resident E’s EMAR showed that the 9:00 P.M. medications included Keppra 500 mg and metformin 1000 mg, each ordered twice daily between 6:00 A.M.–10:00 A.M. and 6:00 P.M.–10:00 P.M. The facility’s written policy required verification of the right resident, right drug, right dose, right route, and right time with a triple check at three steps in the preparation process, which was not followed in this incident.
Failure to Prevent Resident Fall Resulting in Fracture
Penalty
Summary
The facility failed to prevent a fall during care that resulted in a fracture for a resident who was severely cognitively impaired and dependent on staff assistance for all care. The resident was lying on an air mattress without side rails or grab bars, and the bed was positioned by the door. During a dressing change, the resident rolled off the bed between the wall and the bed, resulting in a bruise and skin tear on the right forearm. Initially, first aid was applied, and the resident showed no immediate signs of pain or discomfort. Subsequent observations revealed discoloration and warmth in the resident's right shin, leading to an x-ray that confirmed an acute distal tibia/fibula fracture. The resident was then sent to the emergency room for splinting and later returned to the facility with instructions to remain non-weight bearing and to follow up with an orthopedic surgeon. Interviews with staff indicated that the air mattress was set to a firm setting during the dressing change, which may have contributed to the instability that led to the fall. The facility lacked a specific policy for turning residents in bed, and staff were trained to turn residents side to side based on the type of care being provided. The incident highlighted a failure to maintain a hazard-free environment and implement preventative measures, as outlined in the facility's Fall Management Program Guidelines. The deficiency was identified as part of a complaint investigation.
Removal Plan
- Educate nurses and aides on turning and repositioning resident dependent on staff.
- Educate staff on accident hazards related to air mattress, bed mobility, and falls.
- Conduct return demonstration of proper rolling/turning/repositioning techniques.
Resident Sustains Second-Degree Burn Due to Improper Foot Care
Penalty
Summary
The facility failed to ensure a resident did not acquire a burn during care, resulting in Resident B sustaining a second-degree burn on the left foot. Resident B, who was cognitively intact and had diagnoses including traumatic spinal cord dysfunction and quadriplegia, required extensive staff assistance with all ADLs. The resident's clinical record lacked documentation of an order or care plan related to the use of a blow dryer to dry the resident's feet. On the day of the incident, CNA 2, who had not been trained on using a blow dryer on the resident's feet, dried Resident B's feet at the resident's request. The resident's left foot became red, and blisters later formed, leading to a diagnosis of second-degree burns on the left toes by the wound center. Interviews revealed that the CNA was unaware that the resident could not feel her feet, and the facility's policy on notification of change in condition was not adequately followed in this case. The incident was documented in progress notes and interviews with the resident, CNAs, LPN, and NP. The resident had been having her feet dried with a blow dryer for a long time, as recommended by her podiatrist, but this was the first time CNA 2 had assisted her. The CNA noticed the redness after drying the feet and informed LPN 3, who then notified the DON. The resident's condition was monitored, and treatment was provided, but the lack of proper training and awareness among staff contributed to the incident. The facility's policy on change in condition and the risks associated with heating appliances for residents with paralysis were not adequately addressed, leading to the deficiency.
Failure to Follow Resident's Diet Order
Penalty
Summary
The facility failed to follow a resident's diet order for a mechanical soft diet. During an observation, Resident C was served a lunch plate that did not comply with her prescribed mechanical soft diet. The meal ticket indicated a mechanical soft diet, but the resident was served a regular diet meal consisting of a slice of ham, cheddar hashbrowns, roasted carrots, and a piece of cake. RN 6 confirmed that the resident's diet order in the clinical record was for a mechanical soft diet, which had not been updated by the kitchen. The Speech Therapist also confirmed that the resident should have been served a mechanical soft meal and ordered the correct diet from the kitchen. The Dietary Manager indicated that the cook working in the 600 Hall kitchen was unfamiliar with the residents' diet orders and that the aides should have checked the meal tickets to ensure the correct diet was served. Resident C's diet order, which started on 04/10/24, indicated a mechanical soft diet with extra gravy and no straws. The resident was severely cognitively impaired and had multiple diagnoses, including metabolic encephalopathy, hypertension, heart failure, diabetes, malnutrition, anxiety, and depression. The resident had episodes of coughing or choking during meals or when swallowing medications and had complaints of difficulty or pain with swallowing. The facility's policy on Resident Dining & Nutritional Preferences emphasized the importance of following dietary orders to meet residents' nutritional needs, but this policy was not adhered to in this instance.
Failure to Follow Physician Orders for Blood Thinner Administration
Penalty
Summary
The facility failed to follow physician orders related to the administration of a blood thinner, Coumadin, for a resident. The resident, who was cognitively intact and had diagnoses including fracture, anemia, atrial fibrillation, and hypertension, was observed to be in good condition with no visible bruises or bleeding. However, a review of the clinical records revealed discrepancies in the administration of Coumadin. Specifically, the resident was supposed to receive a 2 mg dose of Coumadin from 04/26/24 through 04/28/24, but this dose was not administered as per the physician's orders. Interviews with the nursing staff, including an RN and the Director of Nursing (DON), indicated a lack of clarity and communication regarding the resident's medication orders. The RN explained the process for obtaining and communicating PT/INR results and coordinating with the physician for any dose changes. Despite this process, the 2 mg dose of Coumadin was not administered as ordered. The DON was unable to explain why the dose was discontinued, despite the order to continue it. The facility's policy on medication administration, which mandates that medications be administered as prescribed, was not followed in this instance.
Failure to Provide Adequate Bathing for Dependent Residents
Penalty
Summary
The facility failed to provide adequate bathing for two dependent residents, Residents C and D, as required by their policies. Resident C, who was severely cognitively impaired and had multiple diagnoses including metabolic encephalopathy, hypertension, heart failure, diabetes, malnutrition, anxiety, and depression, received only 6 out of 20 scheduled showers or complete bed baths since admission. There was only one documented refusal of a scheduled shower or complete bed bath for Resident C. Similarly, Resident D, also severely cognitively impaired with diagnoses including metabolic encephalopathy, anemia, diabetes, and malnutrition, received only 7 out of 11 scheduled showers or complete bed baths from admission until discharge. There was a lack of documentation for one of the scheduled bathing sessions for Resident D. Interviews with facility staff revealed that residents were to be offered showers at least twice a week, with the option for more if requested. The staff were required to document the bathing in the electronic record and fill out a skin sheet after each bath, which was then signed by the nurse and given to the ADON. However, the records for both residents showed significant gaps in the provision and documentation of bathing, indicating a failure to adhere to the facility's policies on bathing and ADL documentation.
Failure to Hold Blood Pressure Medication as Per Physician's Orders
Penalty
Summary
The facility failed to hold a resident's blood pressure medication when the resident's heart rate was outside of the physician's hold parameters. Resident E, who was severely cognitively impaired and had diagnoses including senile degeneration of the brain, anemia, diabetes, heart failure, and hypertension, was prescribed metoprolol succinate with instructions to hold the medication if the heart rate was less than 60. Despite this, the medication was administered on multiple occasions when the resident's heart rate was below the specified threshold. The clinical record review revealed that Resident E received the medication on several dates in March and April 2024 when the heart rate was below 60, with the lowest recorded heart rate being 45. During an interview, an LPN confirmed that the heart rate should be checked before administering the medication and that the medication should not be given if the heart rate is outside the parameters, with the Nurse Practitioner being notified in such cases. The facility's policy on medication administration supports this procedure, indicating that medications should be administered according to the prescriber's written orders.
Failure to Identify and Document Pressure Ulcers
Penalty
Summary
The facility failed to identify and properly document a pressure ulcer for Resident D, who was at high risk for pressure ulcers. During an observation, the resident revealed sores on his bottom that were not present upon admission. The sores included small open areas on the coccyx and buttocks, which were pink in color with no drainage. The resident's clinical record indicated he was always incontinent of bowel and bladder and had no pressure ulcers at the time of admission. However, the record lacked documentation of the newly observed pressure ulcers. Interviews with staff revealed that the dressing had been removed earlier due to increased bowel movements, and there was a lack of communication among staff regarding the resident's wounds. The Qualified Medication Aide (QMA) and Certified Nurse Aide (CNA) working with the resident were unaware of the wounds. The Wound Care Nurse indicated that she relied on nurses and aides to inform her of any new skin issues, but the staff had not alerted her about the resident's condition before the areas became open wounds. The facility's policy on weekly skin observation required nurses and aides to monitor and report any skin impairments. Despite this policy, the staff failed to identify and document the resident's pressure ulcers in a timely manner. The Wound Care Nurse confirmed that the areas were not present on admission and should have been reported before they became open wounds. This deficiency was related to a complaint investigation.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
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Nursing homes near Columbus
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willow Crossing Health & Rehabilitation Center | 0.5 mi | ★★★★★ | 14 | 0 |
| Four Seasons Retirement Center | 2.4 mi | ★★★★★ | 0 | 0 |
| Hickory Creek At Columbus | 2.7 mi | ★★★★★ | 0 | 0 |
| Belmont Health & Rehabilitation, The | 6 mi | ★★★★★ | 9 | 0 |
| Miller's Merry Manor | 8.1 mi | ★★★★★ | 3 | 0 |
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