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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Norwich Springs Health Campus during CMS and state inspections, most recent first.
A resident with cirrhosis, ascites, mood disorder, and alcohol-induced major neurocognitive disorder, and with moderately impaired cognition, was observed sitting on a shower chair in a gown with buttocks exposed and visible from the hallway through an open room door. A CNA left the room quickly after hearing another resident yell and forgot to close the door or pull the privacy curtain, and an RN confirmed the exposure, demonstrating a failure to maintain the resident’s dignity and privacy.
Two residents receiving continuous oxygen therapy did not receive care in accordance with physician orders or facility policy. One resident with sepsis and pulmonary hypertension had an order for 3 L/min via nasal cannula, but surveyors observed the concentrator set at 2 L/min, which an RN confirmed was inconsistent with the order. Another resident with COPD and acute respiratory failure had an order for 2 L/min and monthly tubing changes; surveyors observed the nasal cannula hanging on the bed with prongs pressed against the bed surface, not stored in a sanitary bag, and a CNA placed it on the resident without replacing it. Later, an RN was observed with the concentrator set at 2.5 L/min, above the ordered rate, and did not adjust it, despite a policy requiring oxygen to be given as ordered and equipment kept clean and sanitary.
A resident admitted with a Stage 3 pressure ulcer did not receive appropriate wound treatment, as a protective cream unsuitable for deep wounds was used and no dressing was applied for several days. Additionally, multiple linen layers were used on a low air loss mattress, contrary to manufacturer recommendations for pressure injury care.
The facility failed to maintain a comprehensive water management plan, resulting in abnormal water test results in several areas. Despite the need for flushing and disinfection, these actions were not performed. The Legionella Water Management Plan lacked specific acceptable ranges for water quality measures, and facility documentation showed incomplete testing records. Corporate Maintenance confirmed the absence of necessary actions and specific measures in the plan.
The facility failed to implement comprehensive care plans for several residents, omitting necessary interventions for mobility aids, psychotropic medication use, and other specific needs. This included residents with cognitive impairments and those requiring extensive assistance for ADLs. Interviews confirmed these omissions, indicating a systemic issue in care plan development.
The facility failed to assess and obtain consents or orders for bed rail use for six residents, despite their need for extensive ADL assistance. The facility's policy requires assessments and informed consent, but these were not documented. The DON confirmed the absence of necessary records, indicating a systemic compliance failure.
A facility failed to ensure medications were not left at the bedside, affecting a resident who was cognitively intact and had multiple diagnoses. Medications were found unattended in the resident's room, and the LPN confirmed they were from the night shift. The facility's policy requires observation after administration to ensure ingestion, which was not followed.
The facility failed to ensure timely administration and proper documentation of consents for flu and pneumonia vaccines for three residents. A resident received a flu vaccine after a delay, another received a pneumonia vaccine without documented consent, and a third resident's pneumonia vaccine was not administered despite consent. The ADON confirmed the lack of evidence for these issues, contrary to facility policy.
A facility failed to include the use of bed rails in the baseline care plan for a resident with severe cognitive impairment and multiple medical conditions requiring extensive assistance. The omission was confirmed by MDS Support, despite the facility's policy requiring a 48-hour baseline care plan to be completed upon admission.
A facility failed to assess a resident's elopement risk before removing a Wanderguard bracelet, which was part of the care plan for a resident with severe cognitive impairment and a history of exit-seeking behaviors. Despite a physician's order for daily checks and a policy requiring regular assessments, the bracelet was removed without documentation or reassessment, as confirmed by staff interviews.
A resident with a urinary catheter was found using a leg bag at bladder level, contrary to the care plan requiring the bag to be below the bladder. The facility did not provide leg bags, and the one in use was from a recent hospital discharge. An RN confirmed the setup was incorrect, leading to improper catheter management.
A resident with type two diabetes received an incorrect insulin dose due to an LPN's failure to prime the insulin pen before administration. The LPN was unaware of the requirement to prime the pen, as specified in the manufacturer's instructions, which led to a significant medication error.
Resident Left Exposed and Visible From Hallway Due to Failure to Maintain Privacy
Penalty
Summary
The facility failed to ensure resident dignity and privacy when a cognitively impaired resident was left exposed and visible from the hallway. The resident, who had diagnoses including cirrhosis with ascites, mood disorder, and alcohol-induced major neurocognitive disorder, had a BIMS score of eight, indicating moderately impaired cognition. During an observation, the resident was seen sitting on a shower chair in a gown with buttocks exposed, and this exposure was visible from the open room door in the hallway. A Certified Resident Care Associate and a Registered Nurse confirmed that the resident’s buttocks were visible from the hallway. The Certified Resident Care Associate reported that she had left the resident’s room quickly after hearing a resident in an adjacent room yell and, in her haste, forgot to close the door or pull the privacy curtain, resulting in the resident’s exposed state being visible to others. This incident involved one resident out of three reviewed for dignity, in a facility with a census of 52 residents, and was identified through record review, observation, and staff interviews.
Failure to Follow Oxygen Orders and Maintain Sanitary Oxygen Equipment
Penalty
Summary
The deficiency involves the facility’s failure to provide oxygen therapy services according to physician orders and to maintain oxygen equipment in a sanitary condition for two residents. For one resident with sepsis due to MRSA and pulmonary hypertension, the MDS indicated continuous oxygen use and a physician order dated 3/11/26 specified oxygen at 3 L/min via nasal cannula continuously. On observation, the oxygen concentrator gauge showed delivery at 2 L/min while the resident was resting in bed. A concurrent interview with the RN present confirmed the oxygen was set at 2 L/min, and the RN further confirmed that the physician’s order required 3 L/min. The facility’s SOP for Administration of Oxygen directed staff to verify the physician’s order and to administer oxygen as ordered. For another resident with diagnoses including paroxysmal atrial fibrillation, GI hemorrhage, acute respiratory failure with hypoxia, and COPD, the admission MDS showed the resident was cognitively intact and receiving oxygen therapy. Physician orders dated 2/23/26 required oxygen at 2 L/min via nasal cannula continuously and monthly tubing changes. During observation, the nasal cannula was found hanging on the side of the bed, not stored in a sanitary bag, with the nasal prongs pressed against the side of the hospital bed. A CNA present then placed the same nasal cannula on the resident without replacing it and confirmed it should have been stored in a sanitary bag when not in use. A subsequent observation with an RN showed the oxygen concentrator set at 2.5 L/min, above the ordered 2 L/min, and the RN confirmed the discrepancy without making an adjustment. The facility’s oxygen administration policy required oxygen to be administered as ordered and equipment to be maintained in a clean and sanitary manner when not in use.
Failure to Provide Appropriate Pressure Ulcer Treatment and Mattress Use
Penalty
Summary
A Stage 3 pressure ulcer was present upon admission for a resident with diagnoses including hypertensive chronic kidney disease and peripheral vascular disease. The wound, located on the coccyx, was documented as having serosanguineous drainage and surrounding discoloration. The care plan included interventions such as a pressure reducing mattress and treatment per physician order. However, the initial physician order was for a protective cream to be applied after incontinence episodes, which was not appropriate for a deep wound as indicated by the product's warning label. No dressing was used to cover the pressure ulcer until several days after admission, despite the wound's severity. Additionally, during wound care observation, the resident was found on a low air loss mattress with a fitted sheet, a cloth bed pad, and an incontinence brief, resulting in multiple layers between the resident and the mattress. The mattress user manual specifically recommended avoiding multiple layers of linens or underpads to promote healing of pressure injuries. Staff interviews confirmed that the protective cream was used as a routine order and that multiple layers were present, contrary to manufacturer guidelines. These actions and inactions led to the deficiency cited in the report.
Deficient Water Management Plan and Testing
Penalty
Summary
The facility failed to maintain a comprehensive water management plan, which included monitoring measures and acceptable ranges for water quality. A review of microbiological analyses revealed that several areas within the nursing facility and connected assisted living had abnormal water test results. Specifically, two areas in the nursing facility required site flushing and consideration of disinfection, while five areas required immediate site disinfection. Additionally, five out of six areas in the assisted living section also tested in the abnormal range, necessitating flushing and disinfection. Despite these findings, the facility did not perform the necessary flushing or disinfection procedures. The Legionella Water Management Plan lacked specific information on acceptable ranges for water quality measures such as hardness, total alkalinity, and pH levels. Facility documentation showed some weekly temperature logs but no acceptable limits or evidence of monthly testing for water hardness, alkalinity, and pH. During an interview, the Corporate Maintenance staff confirmed the absence of flushing or disinfection despite abnormal test results and acknowledged the lack of specific measures or ranges in the water management plan. The facility's policy on water management required procedures to reduce Legionella risk and establish control measures, but these were not effectively implemented.
Deficiencies in Care Plan Implementation
Penalty
Summary
The facility failed to implement comprehensive care plans for several residents, leading to deficiencies in addressing their specific care needs. For Resident #27, the care plan lacked interventions related to the use of mobility bars, which are crucial for the resident's mobility and safety. Similarly, Resident #34's care plan did not include interventions for psychotropic medication use or mobility bars, despite the resident requiring extensive assistance for activities of daily living (ADL). Resident #36's care plan also omitted necessary interventions for mobility bars, which were noted as potential enablers for safe transfers and increased mobility. Resident #190, who had severe cognitive impairment and required extensive ADL assistance, did not have a care plan addressing psychotropic drug use or mobility bars. Resident #194's care plan was similarly deficient, lacking interventions for mobility bars and psychotropic drug use, despite the resident's cognitive intactness and extensive ADL assistance needs. Interviews with facility staff confirmed these omissions, highlighting a systemic issue in care plan development and implementation. Additional deficiencies were noted for Resident #3, whose care plan did not address hearing loss or the use of hearing aids, despite physician orders and family requests. Resident #13's care plan failed to include information about a prescribed splint for contracture management, and Resident #28's care plan was not updated to reflect wandering behaviors and the use of a wander guard, even after an elopement incident. These omissions indicate a failure to update care plans to reflect current needs and interventions, as required by facility policies.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to properly assess and obtain consents or orders for the use of bed rails for six residents. These residents, identified as #27, #34, #36, #190, #194, and #196, were all reviewed for bed rail use. The facility's policy requires an individualized nursing observation upon admission, quarterly, and as needed, to address the need for a safety device, medical symptoms for use of the device, and whether the device restricts movement. However, the facility did not complete these assessments or obtain informed consent for the use of bed rails for the residents in question. The medical records of the residents revealed that they required extensive assistance for activities of daily living (ADL), with some residents being cognitively intact and others having severe cognitive impairment. Despite these needs, there were no documented bed rail assessments, informed consents, or physician orders for the use of bed rails. The Director of Nursing confirmed during interviews that the necessary assessments and consents were not present in the electronic health records, indicating a systemic failure to comply with the facility's policy on restraint/enabler use.
Medications Left Unattended at Bedside
Penalty
Summary
The facility failed to ensure medications were not left at the bedside, affecting one resident. Resident #30, who was cognitively intact, was admitted with multiple diagnoses including multiple sclerosis, anemia, shock, gastrointestinal hemorrhage, sepsis, hypertensive heart disease with heart failure, congestive heart failure, non-ST elevation myocardial infarction, pleural effusion, and cardiomyopathy. The resident had physician orders for several medications to be administered between 7:00 P.M. and 11:00 P.M., which were marked as given on the Medication Administration Record for May 2024. During an observation, six medications were found in a medication cup at the bedside of Resident #30, who was not present in the room. An LPN confirmed the presence of the medications and stated she did not administer them. The Director of Nursing verified that the medications were from the night shift medication pass. The facility's policy on medication administration requires that residents be observed after administration to ensure the dose is ingested, and any partial ingestion should be noted on the MAR, which was not adhered to in this case.
Failure to Ensure Timely Vaccination and Consent Documentation
Penalty
Summary
The facility failed to ensure that signed consents were completed and vaccinations were administered timely for flu and pneumonia vaccines, affecting three residents. Resident #28 consented to receive the flu vaccine on two occasions, with the first consent dated 07/25/23 and the vaccine administered on 10/30/23, indicating a delay. Additionally, the pneumonia vaccine was administered on 08/19/23 after a phone call on 08/14/24, suggesting a documentation error in the date. Resident #14 received a pneumonia vaccine on 06/28/23, but the facility could not provide evidence of a signed consent for this vaccination. Resident #25 consented to receive the pneumonia vaccine on 11/01/23, but there was no evidence of administration, and the record stated the vaccine was refused without proper documentation of refusal or consent. During an interview, the ADON confirmed the lack of evidence for the administration of the pneumonia vaccine for Resident #25 and the absence of signed consents for Residents #28 and #14. The facility's policy required signed informed consent for immunizations, which was not adhered to in these cases.
Failure to Address Bed Rails in Baseline Care Plan
Penalty
Summary
The facility failed to address the use of bed rails on the baseline care plan for a resident admitted with multiple diagnoses, including severe cognitive impairment and extensive assistance needs for activities of daily living. The resident's medical record indicated a need for mobility assistance due to conditions such as a wedge compression fracture, displaced intertrochanteric fracture, cardiac arrhythmias, dementia, depression, hypertension, pain, and a history of falls. Despite these needs, the baseline care plan created within 48 hours of admission did not include the use of bed rails or mobility bars, which were later noted in the resident's profile care guide. This omission was confirmed during an interview with MDS Support, who acknowledged that the enabler/mobility bars were not checked on the baseline care plan upon admission. The facility's policy required a 48-hour baseline care plan to be completed within 48 hours of admission, serving as a temporary working care plan until the comprehensive care plan was finalized.
Failure to Assess Elopement Risk Before Wanderguard Removal
Penalty
Summary
The facility failed to ensure a resident was properly assessed before the removal of a Wanderguard bracelet, which is used to prevent wandering and elopement. This deficiency affected a resident with a history of dementia, heart disease, and severe cognitive impairment, who was identified as being at risk for elopement. The resident's care plan included the use of a Wanderguard bracelet due to exit-seeking behaviors, and a physician's order required daily checks of the bracelet's function. Despite these precautions, the Wanderguard bracelet was removed without any documented assessment indicating that the resident was no longer at risk for elopement. Interviews with facility staff, including a registered nurse and the administrative team, revealed that there was no documentation or assessment conducted prior to the removal of the Wanderguard bracelet. The facility's policy required elopement risk assessments upon admission, quarterly, and upon any change in condition, but this protocol was not followed in this instance. The lack of assessment and documentation before the removal of the Wanderguard bracelet represents a failure to adhere to the facility's own policies and procedures for managing residents at risk of elopement.
Improper Catheter Bag Use for Resident
Penalty
Summary
The facility failed to ensure the correct catheter bag was used for a resident, leading to a deficiency in catheter care. Resident #28, who was admitted with a primary diagnosis of urinary tract infection and secondary diagnoses including infection due to an indwelling urethral catheter, was observed with a leg bag at bladder level. This was contrary to the care plan, which required the urinary bag to be maintained below the bladder to prevent urine reflux. The resident's medical history also included chronic kidney disease and benign prostatic hyperplasia with lower urinary tract symptoms. Observations on two occasions revealed that the urine was not flowing freely into the catheter bag, indicating improper catheter management. During an interview, RN #118 confirmed that the facility does not provide leg bags and that the leg bag in use was from the resident's recent hospital discharge. The nurse acknowledged that the leg bag should have been replaced with a regular catheter bag and confirmed that the current setup was incorrect, as the catheter should be positioned below the bladder level.
Failure to Prime Insulin Pen Leads to Medication Error
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by an incident involving the administration of insulin to a resident. The resident, who was admitted with a diagnosis of type two diabetes, was observed receiving six units of lispro insulin from an LPN. The LPN did not prime the insulin pen before administration, which is a necessary step to remove air from the needle and cartridge and ensure the correct dosage is delivered. During an interview, the LPN confirmed that she did not prime the pen and was unaware of the requirement to do so. The manufacturer's instructions for the insulin lispro KwikPen clearly state the importance of priming the pen before each injection to avoid administering an incorrect dose.
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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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Nursing homes near Hilliard
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Darby Glenn Nursing And Rehabilitation Center | 1.1 mi | ★★★★★ | 4 | 0 |
| Trueman Pointe Care Center | 1.2 mi | ★★★★★ | 6 | 0 |
| Mill Run Care Center | 1.3 mi | ★★★★★ | 24 | 0 |
| Mayfair Village Nursing Care Center | 3 mi | ★★★★★ | 19 | 0 |
| The Sanctuary At Tuttle Crossing | 3.2 mi | ★★★★★ | 4 | 0 |
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