Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fountain Circle Care & Rehabilitation Center during CMS and state inspections, most recent first.
Failure to Honor Married Residents’ Rooming Request: Two cognitively intact spouses, married for 66 years, repeatedly asked to share a room, but the facility did not document reasonable efforts to accommodate the request or involve the IDT in the decision. One resident had depression and the other had anxiety, insomnia, and poor appetite, and both expressed distress about being separated until surveyor inquiry prompted a room move.
A resident admitted after femur fracture repair had severe pain on arrival, but staff did not document a follow-up pain assessment after a PRN oxycodone dose, did not timely escalate when pain remained uncontrolled, and the resident was sent to the ED by family due to extreme pain when ordered meds were delayed. After a later fall with worsening back pain, an NP ordered an MRI but discontinued it when insurance would not cover it, and the resident continued to receive PRN oxycodone without adequate relief until the family requested transfer; hospital imaging later showed compression fractures.
A cook was observed exiting a restroom while still wearing an apron, despite facility policy stating aprons are to be worn only in the kitchen and not in bathrooms. The cook acknowledged he should have removed the apron before entering the restroom, and the Dietary Manager, IP/SDC, DON, and Administrator all stated this was against policy and an infection control issue.
QA/QAPI oversight failed to correct repeat pain management and infection control deficiencies. Three residents admitted after orthopedic or surgical conditions did not receive ordered pain medication for many hours because nursing staff did not obtain it from the Narc Box, and multiple staff members were observed breaking IPC practices, including failing to use PPE, skipping hand hygiene, and not disinfecting equipment or therapy items after use. Facility leaders stated they held QA/QAPI meetings and provided education, but the audits did not identify the observed failures.
Failure to implement EBP for a resident with a dialysis catheter. A resident with ESRD and dependence on renal dialysis had a dialysis catheter, but no EBP signage was posted outside the room to alert staff, visitors, and others to gown and glove use during high-contact activities. The resident was not care planned or ordered for EBP until the day surveyors entered the facility, and staff interviews confirmed the resident should have been on EBP on admission.
Failure to Offer Resident Choice for Getting Out of Bed: A resident with intact cognition and diagnoses including muscle weakness, difficulty walking, lymphedema, depression, and anxiety was observed in bed on multiple days and said he was not offered the option to get up. Staff stated they used a list of residents to assist out of bed rather than offering all residents the choice, and the ADL transfer record mostly showed activity did not occur with few refusals documented.
Failure to Provide Nail Care and ADL Assistance: A resident with respiratory failure, generalized weakness, difficulty walking, and moderate cognitive impairment had a care plan for staff-assisted ADLs, but repeated observations showed toenails extending beyond the toes and appearing jagged. The resident said she had asked staff multiple times to trim her nails because they snagged on the sheets, yet the care was not completed during showers or when requested, despite staff stating nail care should be checked and provided routinely.
Failure to Provide Ordered Oxygen Care: Two residents with COPD and chronic respiratory failure had physician orders for O2 at 3 LPM via NC, monthly tubing changes, and humidification checks every shift. Observations showed the concentrators set at 3 LPM, tubing without change dates, and humidification missing or not dated. One resident’s CCP did not include the ordered tubing and humidification interventions, and both residents reported staff had not been changing the tubing or humidification as expected.
An opened, undated vial of Tubersol was found in the Hall B medication refrigerator during observation. The facility policy required medications and biologicals to be stored properly per manufacturer guidance, and the manufacturer stated a Tubersol vial in use for 30 days should be discarded. Staff, including an LPN, the IP/SDC, the DON, and the Administrator, stated multidose vials should be dated when opened so staff would know when to discard them.
The facility failed to ensure residents received mail on Saturdays, affecting all 125 residents. Residents reported not receiving mail on Saturdays, except for special deliveries. The ABOM and Administrator confirmed that mail delivered after 5:00 PM was not sorted until Monday due to lack of staff. The facility's policy stated residents' right to privacy in mail was not upheld.
The facility failed to properly store and handle medications, biologicals, and vaccines, leading to deficiencies in medication management. Observations revealed overcrowded medication refrigerators, improper temperature storage, and expired medications in medication carts. Staff interviews highlighted lapses in adherence to facility policies, with nursing staff responsible for labeling and discarding expired or improperly stored medications. The facility's Infection Preventionist and acting DON emphasized the importance of following guidelines to ensure medication efficacy and resident safety.
The facility failed to provide required Notice of Transfer or Discharge forms to residents and their representatives during hospital transfers. This deficiency affected four residents, including those with cognitive impairments, who did not receive information on transfer reasons, dates, locations, or appeal rights. Interviews revealed staff were unaware of the requirement, leading to a lack of implementation.
The facility failed to maintain an effective infection prevention and control program, as evidenced by a nurse not wearing a gown during wound care for a resident and a lack of proper signage. Additionally, a SRNA did not perform hand hygiene after exiting a room with a resident on contact precautions for C. diff. The facility's infection control policies were not reviewed or updated annually.
Failure to Honor Married Residents’ Request to Share a Room
Penalty
Summary
The facility failed to ensure two married residents were permitted to share a room when both lived in the facility and both consented. Resident 2 and Resident 77 had been married for 66 years, both were cognitively intact with BIMS scores of 14 out of 15, and both expressed a desire to reside together. The facility’s own policy stated residents have the right to share a room with their spouse when both spouses reside in the facility and both consent, but there was no documented evidence that the facility made reasonable efforts to accommodate the couple’s request before surveyor intervention. Resident 2 was admitted with diagnoses including acute kidney failure and major depressive disorder. During a care conference, he stated his wife would be moving in soon and he wanted to share a room with her. His care plan identified depression, sadness, tearfulness, self-isolation, and risk for psychosocial decline, but it did not document his preference to live with his spouse. Later progress notes documented that he and Resident 77 had been married for 66 years and had lived together at home before entering LTC, yet the record still did not show that the facility addressed his request, attempted to accommodate a shared room, or involved the IDT in the decision. There was also no documented evidence that he declined to share a room with his wife. Resident 77 was admitted with diagnoses including generalized anxiety disorder, major depressive disorder, unspecified mood disorder, and paradoxical insomnia. Her care plan identified altered mood state, sadness, anxiety, decreased interest in activities, and risk for psychosocial decline, but it also did not document her preference to reside with her spouse. Her progress notes stated she came to the facility to be closer to her husband and planned for them to move into a room together once one became available. The notes also described significant anxiety, distress, poor sleep, and poor appetite related to the living situation and her husband’s unhappiness at the facility. The Social Worker stated the couple had requested to share a room and that the facility had not been able to accommodate the request because of census and room configuration issues, and that it would likely be several more weeks before they could reside together. After surveyor inquiry, staff prepared to move the couple into a shared room, and both residents later stated they wanted to continue residing together.
Pain management was not consistently assessed or escalated for a resident with severe post-surgical and post-fall pain
Penalty
Summary
The facility failed to provide safe, appropriate pain management for a resident admitted after surgical repair of a right distal femur fracture. The resident had diagnoses including periprosthetic fracture around the right hip prosthesis, fracture of the lower end of the right femur with routine healing, chronic pain syndrome, and age-related osteoporosis. On admission, the resident reported severe pain, and the care plan identified pain related to the surgical wound with interventions including analgesics, repositioning, elevation, and notifying the physician if pain was ineffective to control. The resident’s hospital discharge paperwork showed ongoing pain medication orders, including acetaminophen, gabapentin, methocarbamol, and oxycodone for severe pain. After admission, the resident complained of pain rated 9/10 shortly after arrival, and an LPN obtained a one-time oxycodone dose from the emergency kit because the pharmacy had not yet delivered the resident’s medications. The facility did not document a follow-up pain assessment after that PRN dose to show whether it was effective. The resident continued to report pain, but staff did not complete a follow-up assessment or notify the physician that the medication was ineffective. The resident’s prescribed medications were not ordered as STAT, and the resident’s family ultimately called 911 because the resident remained in extreme pain and the medications were not available at the facility. The resident was transferred to the hospital ED, where she received additional opioid pain medication before returning to the facility. After the resident later fell while attempting to get up independently, she complained of increased lower back pain. X-rays were abnormal, and the NP ordered an MRI of the lumbar and thoracic spine. When staff learned the resident’s insurance would not cover the MRI, the NP discontinued the MRI order and instructed staff to observe for worsening symptoms. The resident continued to have significant back pain despite repeated PRN oxycodone doses, and additional intervention did not occur until the family requested transfer to the hospital ED. Hospital imaging then identified a T1 compression fracture and T5 superior endplate fracture, and the resident was admitted for pain control and further evaluation.
Apron Worn Into Restroom
Penalty
Summary
The facility failed to prepare and serve food in accordance with professional standards for food service safety when a cook was observed exiting a restroom while still wearing an apron. The facility policy stated that aprons were to be worn in kitchens while prepping food and were not to be worn in halls, outside, or bathrooms at any time. During observation, the restroom the cook had exited did not have a hanger on the back of the door. In interview, the cook stated he had taken his apron off and hung it on the back of the door, but also stated he should have removed the apron before entering the restroom because of the potential for cross contamination. The Dietary Manager stated it was against policy to wear aprons into the restroom and acknowledged the potential for cross contamination if staff failed to remove an apron before entering. The IP/SDC, DON, and Administrator each stated that wearing an apron into a restroom was not appropriate and identified it as an infection control issue.
QA/QAPI Oversight Failed to Correct Pain Management and Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain an effective QA/QAPI program that identified quality deficiencies and ensured appropriate plans of action were developed and implemented to correct them. Review of the facility’s policies, QA/QAPI committee minutes, and Plan of Correction showed that the facility had ongoing monitoring activities related to pain management and infection control, but the survey findings showed repeat deficiencies in both areas and that the committee did not provide effective oversight or follow-up of identified concerns. The pain management deficiency involved three residents admitted after orthopedic and surgical conditions. One resident was admitted after a closed right fibula fracture, another after bilateral knee replacement with septic arthritis, bilateral wound vac placement, multiple lower extremity abscesses, and osteomyelitis, and a third after open reduction internal fixation of the left ankle and tibia/fibula fracture. Although pain medication had been ordered for each resident, nursing staff did not obtain the medication from the available emergency medication resources in the facility’s Narc Box, and the residents did not receive prescribed pain medication until approximately 8 hours and 40 minutes, 9 hours, and 21 hours and 37 minutes after admission, respectively. The infection control deficiency was identified through direct observation of multiple staff members. An ABOM entered a resident’s room under Contact Isolation for ESBL in a wound without PPE, handled the resident’s water pitcher, did not perform hand hygiene, and then handled the shared ice bin and ice scoop. An LPN was observed providing care to residents without hand hygiene, without a gown while caring for a resident on EBP, and without disinfecting equipment after use. The same LPN also failed to clean and disinfect a glucometer and timer after a fingerstick. A PTA provided direct care to a resident on contact isolation without PPE and reused a resistance band after it fell on the floor without cleaning or disinfecting it. Interviews with facility leaders showed they had provided education and held QA/QAPI meetings, but they also acknowledged that audits had not identified these breaks in practice and that no concerns had been discussed during the meetings.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for one sampled resident, R71, who had end stage renal disease and dependence on renal dialysis. The facility policy stated that Enhanced Barrier Precautions (EBP) were indicated for residents with chronic wounds and/or indwelling medical devices regardless of MDRO status. R71 had a dialysis catheter, but on observation there was no EBP signage posted on the door or wall outside the resident’s room to alert staff, visitors, and other residents to the need for gown and glove use during high-contact activities. R71 was not care planned for EBP until the date of State Survey Agency entry, and the order for EBP was also entered that same day. During interviews, an LPN stated R71 should have been in EBP and that residents receiving hemodialysis with external access should be in EBP. The IP/SDC stated R71 should have been in EBP on admission, and the Interim DON and Administrator both stated they expected signage to be posted and appropriate PPE to be used for residents in EBP, including residents with a dialysis catheter.
Failure to Offer Resident Choice for Getting Out of Bed
Penalty
Summary
The facility failed to promote and facilitate resident self-determination through support of resident choice related to getting out of bed for one resident. The resident was admitted with diagnoses including muscle weakness, difficulty walking, lymphedema, need for assistance with personal care, depression, and anxiety. The resident’s quarterly MDS showed a BIMS score of 14 out of 15, indicating intact cognition. Observations on multiple days showed the resident remained in bed, and during interviews the resident stated he had not been offered assistance to get out of bed. He said it would be nice to be offered the option and that he was very seldom asked if he wanted to get out of bed. He stated he was not offered on Monday, Tuesday, or Wednesday during the observation period. The resident’s care plan included interventions related to social isolation and providing assistance to activities of choice as needed, and a PT note stated a mechanical lift continued to be used for out-of-bed transfers. Staff interviews showed the resident was not routinely offered the choice to get up. An SRNA stated she had not offered to assist the resident up because he was not on the list of residents to be assisted that day, and said the list was passed from the previous shift. Other SRNAs stated they assisted only residents on a list and did not offer all residents the chance to get up. The LPN/unit manager stated the resident should be offered assistance out of bed every day and that refusals should be documented, but the ADL transfer records showed the majority of responses were documented as activity did not occur, with only nine refusals documented across four months.
Failure to Provide Nail Care and ADL Assistance
Penalty
Summary
The facility failed to provide ADL assistance to a dependent resident by not maintaining good personal hygiene, specifically nail care, for a resident admitted with acute and chronic respiratory failure, generalized muscle weakness, difficulty walking, and need for assistance with personal care. The resident’s quarterly MDS showed a BIMS score of 12, indicating moderate cognitive impairment, and the care plan identified a self-care deficit related to impaired physical functioning and medical conditions requiring staff assistance for adequate completion of ADL care. Facility policy stated staff would support residents with ADLs and provide the assistance needed for residents unable to perform their own care. Observations on multiple days showed the resident’s toenails extended well beyond the tips of the toes and appeared jagged and rough. During interview, the resident stated she had repeatedly asked staff to trim her toenails because they were snagging on the sheets, but staff told her they would return and never did. Staff interviews indicated nail care was expected to be assessed and performed during showers or when requested, and several staff members stated nail care should have been completed for the resident. On the day the resident returned from a shower, nail care had not been performed.
Failure to Provide Ordered Oxygen Care
Penalty
Summary
The facility failed to ensure that residents who required respiratory care received oxygen therapy consistent with physician orders and the facility’s policy. The policy titled Oxygen Administration required staff to confirm complete physician orders, determine the appropriate oxygen source and equipment, and change oxygen tubing monthly and as needed. The deficiency involved 2 of 4 sampled residents reviewed for respiratory care, R6 and R48, both of whom had diagnoses including COPD and chronic respiratory failure and were ordered to receive oxygen at 3 LPM via nasal cannula, with tubing changes monthly and humidification checked every shift and changed when empty. For R48, the record showed orders for oxygen tubing to be changed monthly and humidification to be checked every shift and changed when empty. The care plan also included oxygen use and CPAP, with interventions to change oxygen tubing monthly and as needed and to check the humidification bottle every shift and change it when empty. However, observations on multiple days showed the oxygen concentrator set at 3 LPM, the tubing without an identification date for when it was last changed, and the humidification bottle not dated. The resident stated staff rarely changed the tubing and rarely changed the humidification bottles, and later stated staff had not changed the tubing or replaced the humidification bottles since she last spoke with the surveyor. For R6, the record showed orders for oxygen at 3 LPM via nasal cannula, tubing to be changed monthly, and humidification to be checked every shift and changed when empty. The care plan identified oxygen dependence and risk for active infection, but it did not include interventions for monthly tubing changes or humidification checks as ordered. Observations on multiple days showed the oxygen concentrator set at 3 LPM, the tubing without an identification date for when it was last changed, and no humidification attached. The resident stated she could not recall the last time staff changed the tubing because it had been so long and stated there was no humidification attached to the concentrator. Staff interviews indicated nursing staff were responsible for assessing oxygen tubing, humidification, and rate, and the Administrator stated tubing and humidification should be labeled with the date of change and checked every shift.
Undated Tubersol Vial in Medication Refrigerator
Penalty
Summary
The facility failed to ensure drugs and biologicals were labeled in accordance with accepted professional principles, including the required accessory and cautionary instructions and expiration date when applicable, for 1 of 3 medication refrigerators reviewed in Hall B. During observation of the Hall B medication refrigerator, a vial of Tuberculin Purified Protein Derivative (Tubersol) was found opened and undated. The facility policy titled Medication Storage stated medications and biologicals are to be stored properly, following manufacturer or provider pharmacy recommendations, to maintain integrity and support safe, effective drug administration. The manufacturer’s guidance for Tubersol stated that a vial entered and in use for 30 days should be discarded. Staff interviews confirmed that multidose vials should be dated when opened so staff would know when to discard them, and the DON and Administrator stated it was their expectation that medications be dated when opened to ensure residents were not administered expired doses.
Failure to Deliver Mail on Saturdays
Penalty
Summary
The facility failed to ensure that residents had the right to receive mail delivered to the facility on Saturdays, affecting all 125 current residents. During a group interview, Resident Council members reported not receiving mail on Saturdays, except for special package deliveries. It was confirmed by the Assistant Business Office Manager (ABOM) and the Administrator that mail delivered from the Post Office on Saturday after 5:00 PM was not sorted or delivered by staff until the following Monday. The facility's policy on Resident Rights, revised in January 2025, stated that residents should be treated with respect and dignity, including ensuring their right to privacy in sending and receiving mail. Interviews with several residents revealed that mail was delivered from the Post Office on Saturdays, but if it arrived after 4:30 PM, it was not sorted or delivered. The Social Services Director (SSD) typically sorted the mail during the week, but was unavailable on weekends, preventing mail distribution. The ABOM acknowledged the issue and mentioned contacting the Post Office to discuss it. The Administrator confirmed that the facility was one of the last stops on the postal carrier's route, resulting in late mail delivery on Saturdays, and stated that no front office staff were available after 5:00 PM to sort the mail. Both the ABOM and the Administrator recognized the residents' right to receive mail on Saturdays as essential for their well-being and quality of life.
Deficiencies in Medication Storage and Handling
Penalty
Summary
The facility failed to ensure proper storage and handling of drugs, biologicals, and vaccines, leading to deficiencies in medication management. Observations revealed that medication refrigerators in the A, B, and D Hall Units were overcrowded, preventing proper airflow, and stored medications outside the recommended temperature parameters. This included influenza and COVID-19 vaccines, as well as various resident medications. Additionally, expired medications were found in the D Hall Unit's medication cart, and opened medications were not dated or stored properly in the B Hall Unit's medication cart. Interviews with staff, including the D Hall Unit Manager and the Administrative/Corporate Consultant, highlighted lapses in adherence to facility policies regarding medication storage and expiration. The D Hall Unit Manager acknowledged that the nursing staff was responsible for labeling and discarding expired or improperly stored medications. The Administrative/Corporate Consultant emphasized the importance of removing expired medications to maintain resident safety, noting that expired medications lose their effectiveness. Further observations in the B Hall Unit revealed improperly stored medications, such as a Zofran tablet without a resident label and opened packages of albuterol nebulizer solution not protected from light. The B Hall Unit Manager confirmed that nursing staff should date opened medications and discard expired or improperly stored items. The facility's Infection Preventionist/Staff Development Coordinator and the acting Director of Nursing reiterated the importance of following manufacturer's guidelines for medication storage to ensure efficacy and resident safety. However, inconsistencies in monitoring and adherence to policies were evident, contributing to the deficiencies observed.
Failure to Provide Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide timely and appropriate notification to residents and their representatives regarding transfers or discharges to the hospital. Specifically, the facility did not issue the required Notice of Transfer or Discharge forms, which should include the reason for the transfer, the date, the location, and the resident's appeal rights, along with contact information for the state Long-Term Care Ombudsman. This deficiency was identified in four out of five residents reviewed for hospitalizations. For Resident 47, who was cognitively intact, there was no evidence in the medical record that she or her representative received the necessary notice when she was transferred to the hospital due to a critically elevated potassium level. Similarly, Resident 90, also cognitively intact, did not receive the required notice when transferred for hip pain following a fall. Resident 110, who had severe cognitive impairment, and his representative did not receive the notice when he was transferred due to a critically low potassium level. Resident 25's representative confirmed not receiving the notice when the resident was sent to the hospital. Interviews with facility staff, including nurses and administrative personnel, revealed a lack of awareness and implementation of the Notice of Transfer or Discharge form. Staff members, including LPNs, RNs, and the Business Office Manager, were not providing the form to residents or their representatives. The acting Director of Nursing and the Administrator acknowledged the oversight and indicated that the correct procedure was not being followed prior to the surveyor's findings.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by deficiencies observed in the care of two residents. For one resident, a registered nurse did not wear a gown while performing wound care, and there was no Enhanced Barrier Precautions (EBP) sign on the resident's door. The nurse admitted to forgetting to wear the gown, which is crucial for preventing the spread of germs during wound care. The Assistant Director of Nursing confirmed that staff should wear gowns and gloves for wound care and that precaution signs should be posted on residents' doors. In another instance, a State Registered Nurse Aide (SRNA) failed to perform proper hand hygiene after exiting a room with a resident on contact precautions for Clostridium difficile (C. diff). The SRNA moved a mechanical lift out of the room and entered another resident's room without washing hands with soap and water, as required for C. diff precautions. The interim Director of Nursing and the Administrator both stated that staff are expected to wash their hands with soap and water when exiting rooms with enteric precautions due to C. diff. The facility's infection control policies were not reviewed or updated annually, as required. The Administrator acknowledged that infection control policies should be updated yearly and that corporate was responsible for updating and disseminating these policies. The President of Clinical Operations confirmed that the clinical department ensures policies are up-to-date and accurate, with old policies archived in a web-based program.
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Illustrative
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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.
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Nursing homes near Winchester
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Willows At Hamburg | 11.9 mi | ★★★★★ | 10 | 0 |
| Lexington Premier Nursing & Rehab | 12.2 mi | ★★★★★ | 0 | 0 |
| Bourbon Heights Nursing Home | 13 mi | ★★★★★ | 8 | 0 |
| Bluegrass Care & Rehabilitation Center | 14.3 mi | ★★★★★ | 1 | 0 |
| Hartland Park Health & Rehabilitation | 14.8 mi | ★★★★★ | 13 | 0 |
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