Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Hillspring Health Care & Rehab during CMS and state inspections, most recent first.
A resident with dementia, anxiety, CKD stage 3, CHF, and mild cognitive impairment had her personal cell phone removed from her room and placed in the med cart because staff said she was confused and might misplace it. RN, NAT, SSD, and the Administrator were aware the phone remained away from the resident for multiple days, despite the facility policy stating residents should not be limited in retaining personal items in their room.
Failure to maintain privacy during personal care. A resident who was cognitively intact and dependent on staff for toileting received peri care in a semi-private room while privacy curtains were not pulled, door window coverings were open, and the outside window was open with cars passing by. Two CNAs confirmed the curtains and coverings should have been closed, and the ADON stated CNAs should close privacy curtains and window coverings during personal care.
Failure to report allegation of physical abuse: A resident with dementia, CKD, CHF, anxiety, and a history of falls stated that a CNA pushed her during care, though she appeared confused and gave inconsistent information and no injuries were observed. The allegation was documented in a progress note, but the SRI review showed it was not reported to the State Survey Agency, and the Administrator stated the nurse who documented it did not report it to anyone.
A resident with multiple medical conditions was mistakenly given Meclizine, a medication not ordered for them, after a nurse administered it via PEG tube instead of to the intended recipient. The error was identified through documentation and interviews, and the resident experienced some dizziness but no lasting effects.
A facility failed to ensure interdisciplinary team attendance and resident invitation to care conferences, affecting a resident with multiple diagnoses. The resident, who was cognitively intact, was not informed of care conference dates, and only the Social Service Designee attended one conference. The facility's policy requires interdisciplinary involvement and resident participation, which was not followed.
A resident with type one diabetes mellitus received an insulin injection without the required priming of the insulin pen-injector, resulting in a significant medication error. The RN administering the insulin did not perform the necessary safety test as per the manufacturer's instructions, which is a critical step to ensure accurate dosing. This incident was identified during a complaint investigation.
Resident’s Personal Cell Phone Removed and Kept in Medication Cart
Penalty
Summary
The facility failed to ensure staff allowed a resident to have her personal cell phone. Resident #2 was admitted with chronic diastolic heart failure, chronic kidney disease stage three, dementia, anxiety disorder, history of falling, and mild cognitive impairment. The MDS assessment showed the resident had moderately impaired cognition and required set up assistance with eating and personal hygiene. A progress note documented that the resident’s cell phone was placed in the A hall medication cart to avoid it getting misplaced due to resident confusion. RN #10 stated she placed the resident’s personal cell phone in the medication cart because the resident was so confused and did not recall whether other staff were informed. A NAT confirmed that nurses removed the resident’s personal cell phone from her room for multiple days. The SSD stated she was notified that the cell phone was missing and that it had been in the nursing medication cart for six days away from the resident, and the Administrator confirmed being made aware of the situation on 05/15/26. The facility policy stated it should not limit a resident’s ability to retain or have personal items in their room.
Failure to Maintain Privacy During Personal Care
Penalty
Summary
The facility failed to maintain Resident #43’s privacy during personal care. Resident #43 was admitted with diagnoses including hemiplegia and hemiparesis following cerebrovascular disease, vascular dementia, anxiety disorder, and major depressive disorder, and the MDS indicated the resident was cognitively intact and dependent on staff for toileting. During observation, two CNAs provided peri care to the resident in a semi-private room while the privacy curtains on both sides were not pulled, the door window coverings were not closed, and the window to the outside street and parking lot was open with cars passing by. Both CNAs confirmed the privacy curtains and window coverings should have been closed, and the ADON stated CNAs should close privacy curtains and window coverings when providing personal care. The resident rights handbook stated residents have the right to privacy during medical examination or treatment and in the care of personal or bodily needs.
Failure to Report Allegation of Physical Abuse
Penalty
Summary
The facility failed to ensure that all allegations of physical abuse were reported to the State Survey Agency. Resident #2, who was admitted with chronic diastolic heart failure, chronic kidney disease stage three, dementia, anxiety disorder, a history of falling, and mild cognitive impairment, had an MDS assessment showing moderately impaired cognition and dependence on staff for bathing, with set-up assistance needed for eating and personal hygiene. A progress note documented that the resident exhibited behaviors and stated that a CNA pushed her during care; the resident appeared confused and gave inconsistent information when questioned further, and no injuries, redness, bruising, or other signs of trauma were observed. The facility’s SRI review from 06/06/26 through 06/16/26 showed no allegation of physical abuse involving the resident being pushed by a CNA was reported to the State Survey Agency. During interview, the Administrator stated the nurse who documented the progress note did not report the allegation to anyone and confirmed the investigation started when the information was discovered. The facility policy titled Abuse, Neglect, Misappropriation of Property required staff to report all incidents and allegations of abuse, neglect, mistreatment, exploitation, and misappropriation of resident property.
Medication Administration Error: Wrong Resident Received Unordered Medication
Penalty
Summary
A medication administration error occurred involving a resident with medical diagnoses including pulmonary hypertension, autonomic nervous system disorder, left hemiplegia, and atrial fibrillation. The resident, who was cognitively intact and required varying levels of staff assistance for daily activities, was mistakenly given Meclizine via PEG tube, a medication for which there was no physician order in the resident's medical record. The error was documented on a communication form and a facility medication error report, both indicating that the medication was intended for the resident's roommate, but was administered to the wrong individual. The facility's policy on medication administration requires staff to cross-check the physician's order, medication administration record, and drug container label to ensure accuracy. Despite these procedures, the nurse administered the medication to the incorrect resident after the roommate requested it. The incident was confirmed through interviews with the resident and the facility administrator, as well as through review of the medical record and facility documentation. The resident reported experiencing some dizziness following the error but had no lasting effects.
Failure to Ensure Interdisciplinary Team Attendance and Resident Invitation to Care Conferences
Penalty
Summary
The facility failed to ensure that the interdisciplinary team members attended care conferences and that the resident was invited to these conferences. This deficiency affected a resident who was admitted with diagnoses including skin cancer, anxiety, chronic obstructive pulmonary disease, and type two diabetes mellitus. The resident was cognitively intact according to the quarterly Minimum Data Set assessment. The care conference notes revealed that only the Social Service Designee attended the conference on one occasion, and on other occasions, the resident or their representative did not attend, despite documentation indicating otherwise. Interviews with the resident and the Social Service Designee confirmed that the resident had never attended a care conference, and there was no documentation to prove that the resident or their representative was informed of the care conference dates. The facility's policy requires that each discipline reviews the patient's problems, goals, and interventions during care conferences, and that the patient or responsible party is part of the decision-making process. However, the facility did not adhere to this policy, as evidenced by the lack of interdisciplinary team involvement and failure to notify the resident or their representative.
Failure to Prime Insulin Pen Leads to Medication Error
Penalty
Summary
The facility failed to ensure that a staff member properly primed an insulin pen-injector, leading to a significant medication error. This incident involved a resident with type one diabetes mellitus who was cognitively intact and required insulin injections. The resident had a physician's order for Lantus SoloStar, a long-acting insulin, to be administered twice daily. During an observation, a registered nurse (RN) was seen administering the insulin without performing the necessary priming procedure, which is a safety test required by the manufacturer's instructions. The RN confirmed during an interview that she did not prime the insulin pen-injector before administering the dose. The manufacturer's instructions clearly state that a safety test must be performed before each injection to ensure accurate dosing. The facility's policy on insulin administration, revised in January 2023, mandates that insulin be administered safely and consistently as prescribed. This deficiency was identified during a complaint investigation and affected one of the five residents observed for medication administration.
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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.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Springboro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Otterbein Springboro | 2.3 mi | ★★★★★ | 9 | 0 |
| Momentous Health At Franklin | 3.6 mi | ★★★★★ | 0 | 0 |
| Austin Trace Health And Rehabilitation | 4 mi | ★★★★★ | 1 | 0 |
| Carlisle Manor Health Care Inc | 5.4 mi | ★★★★★ | 1 | 0 |
| Sycamore Trails Post Acute | 5.5 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.