Below 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 Springmeade Healthcenter during CMS and state inspections, most recent first.
The facility did not timely transcribe or implement wound care orders for several residents admitted with or at risk for pressure ulcers, resulting in delayed treatment, incomplete wound assessments, and actual harm to a resident whose pressure ulcer worsened. Wound care interventions and physician orders were not initiated as required, and documentation was incomplete or inconsistent, as confirmed by staff and record review.
Multiple residents and a family member reported that meals, especially breakfast and dinner, were often served cold, with food temperatures observed to be below required standards. Staff confirmed that the use of insulated plates instead of metal plates contributed to the issue, and only certain halls had access to metal plates due to supply limitations. Facility policy required hot foods to be held at 135°F or higher, but sampled food items were served well below this temperature, affecting the palatability and safety of meals for all residents.
The facility did not maintain a clean kitchen environment, with visible buildup of substances on light panels, vents, and windows, and failed to ensure safe food handling practices. An ADM was observed using the same gloves to touch both food and various surfaces without changing them, leading to potential cross-contamination. These deficiencies affected all residents receiving meals from the kitchen.
Multiple deficiencies were identified in the facility's infection prevention and control program, including staff not wearing required PPE during care for residents on Enhanced Barrier Precautions, inadequate hand hygiene during wound care, incomplete infection tracking and monitoring, and lack of updated policies and procedures for Legionella prevention. Staff were often unaware of which residents required EBP due to unclear signage, and water testing revealed positive Legionella results without timely intervention or notification of health authorities.
A resident with impaired cognition and multiple health issues experienced a change in condition requiring new medications and lab tests. Although the NP and physician were notified and interventions were implemented, there was no documentation or evidence that the resident's family or representative was informed of these changes. Staff interviews confirmed that family notification did not occur, and the facility could not provide a change of condition policy when requested.
A resident with multiple complex diagnoses was found to have scattered bruising on both upper extremities during a second skin assessment, with no documentation of an investigation into the cause. The DON and Unit Manager were unaware of the injury and the resident's concerns about rough handling during mechanical lift transfers until prompted by a surveyor, despite facility policy requiring investigation of such incidents.
A resident with a suprapubic catheter and complex medical history had a clear preference for having catheter changes performed by a urologist in the physician's office, but this preference was not documented in the care plan. Facility staff continued to follow standing orders for in-facility catheter changes, and the care plan was not updated to reflect the resident's wishes, as confirmed by both the resident and the MDS RN.
A resident with significant cognitive impairment and multiple medical conditions did not receive needed assistance with oral care and denture use, as required by her care plan. Staff were unaware of her need for dentures, resulting in her being without them during meals and unable to eat most of her food.
Two residents who valued group activities reported insufficient opportunities for participation, with facility-led activities ending early in the day and limited evening options that were resident-driven and not inclusive. Staff confirmed the lack of structured activities beyond the afternoon, and care plans focused mainly on independent pursuits rather than group engagement.
Three residents with skin impairments did not receive timely assessment, clear physician orders, or appropriate documentation for their wounds. In one case, a wound was not treated for two days after discovery, in another, unclear orders led to incomplete wound care, and in a third, a skin injury was not documented or reported to nursing or medical staff as required by facility policy.
Three residents experienced falls or accidents due to the facility's failure to conduct thorough investigations, identify hazards, and implement individualized interventions. One resident with dementia had multiple unwitnessed falls without comprehensive root cause analysis or detailed documentation. Another resident was injured when a CNA transported her in a wheelchair without foot pedals. A third resident with multiple fractures had several falls, with incomplete investigations and unclear documentation. Facility leadership confirmed that required documentation and analysis were not consistently performed.
A resident with impaired cognition and incontinence exhibited symptoms of a UTI and was prescribed cefuroxime, but staff failed to initiate the antibiotic as ordered despite its availability, resulting in a two-day delay in treatment. Nursing staff and the DON confirmed the medication should have been started immediately, but the facility's medication administration policy was not followed.
A resident with multiple comorbidities was prescribed Vancomycin for C-Diff, but due to pharmacy delays and lack of order update, three initial doses were missed and the full seven-day course was not completed. The DON confirmed the incomplete administration, and the resident was later hospitalized with sepsis and pancolitis.
Surveyors found that medications, including antifungal powder and topical creams, were left unsecured in the rooms of three residents with complex medical needs. These medications were present without proper labeling, physician orders, or oversight by licensed staff, in violation of medication storage protocols.
Failure to Timely Implement and Document Pressure Ulcer Care
Penalty
Summary
The facility failed to transcribe and implement treatment orders in a timely manner for the care of pressure ulcers for multiple residents, resulting in actual harm to one resident and placing others at risk for more than minimal harm. One resident was admitted with a Stage 2 pressure ulcer to the sacrum/coccyx area and did not receive any treatment or intervention from the facility for several days, despite clear documentation from the hospital regarding the wound. The wound was not treated until several days after admission, during which time it worsened to an unstageable wound. Documentation and assessment of the wound were incomplete, with missing measurements and delayed initiation of physician-ordered treatments. Another resident was identified as high risk for skin breakdown and developed a stage three pressure ulcer that was not measured or staged at the time of discovery. The wound was only identified during a weekly skin assessment, and the appropriate wound care interventions were not implemented until after the wound had progressed. The nurse and DON confirmed that the wound should have been identified and measured sooner, and that the delay in assessment and intervention contributed to the deficiency. Additional residents were admitted with existing wounds, but the facility failed to transcribe and implement hospital discharge wound care orders upon admission. Wound assessments were incomplete, with missing measurements and inconsistent documentation regarding the type and stage of wounds. Treatments were not initiated until several days after admission, and there were delays in obtaining wound physician assessments and implementing their orders. These failures were confirmed by staff interviews and review of medical records, and were not in accordance with facility policy or national guidelines for pressure injury care.
Failure to Serve Meals at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure that meals were served to residents at a safe and palatable temperature, as evidenced by multiple resident and family interviews, staff interviews, direct observation, and policy review. Several residents reported that their meals, particularly breakfast and dinner, were often served cold, especially when delivered to their rooms or to the 300 hall, which was the last to receive trays. One resident's daughter expressed concern due to her father's poor appetite, which was further impacted by the cold food. Direct observation confirmed that food items such as eggs and oatmeal were served below the required temperature, and the taste was not palatable. The Assistant Dietary Manager acknowledged that the use of insulated plates instead of metal plates contributed to the issue, and that only two halls had access to metal plates due to supply limitations from the previous company. Review of the facility's policy indicated that hot foods should be held at 135 degrees or higher to ensure safety and palatability, and reheated foods should reach 165 degrees. However, sampled food temperatures were significantly below these standards, with eggs at 92.5 degrees and oatmeal at 119 degrees. The facility census was 87, and there were no residents who were NPO (nothing by mouth), indicating that all residents could potentially be affected by this deficiency.
Failure to Maintain Kitchen Cleanliness and Safe Food Handling Practices
Penalty
Summary
The facility failed to maintain a clean kitchen environment and did not ensure food was served in a safe manner, affecting all residents who received meals from the kitchen. Observations revealed multiple sanitation issues, including five ceiling light panels in the dishwasher area and three sets of five lights across the kitchen with a grey flaky substance present either inside or on the outside of the panels. A vent in the dishwasher area was noted to have a thick black substance on its exterior. Additionally, four kitchen windows had splashes of a white substance, and their screens were covered with a thick layer of grey particles. One window was open during the observation, allowing wind to blow into the kitchen. The Culinary Manager confirmed these cleanliness issues. During a tray line observation, the Assistant Dietary Manager was seen serving food after washing her hands and donning gloves. However, she used her gloved hands to touch both food items and various surfaces, such as meal tickets and aluminum foil, without changing gloves between tasks. She handled the vegetable lasagna directly with her gloved hand and then used the same gloves to pick up garlic bread and manipulate other items, failing to prevent cross-contamination. The Assistant Dietary Manager acknowledged that she should have changed gloves or used utensils as per the facility's handwashing policy, which requires handwashing and glove changes to prevent cross-contamination when handling exposed food.
Failure to Implement Effective Infection Prevention and Control Program
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program, as evidenced by multiple deficiencies in staff adherence to Enhanced Barrier Precautions (EBP), hand hygiene, infection tracking, and water safety protocols. Staff members did not consistently wear required personal protective equipment (PPE) such as gowns and gloves when providing care to residents under EBP, including during dressing changes and wound care. In several instances, staff were unaware of which residents required EBP due to inadequate signage and communication, and PPE was not readily available or recognized in resident rooms. For example, a registered nurse performed a dressing change for a resident on EBP using only gloves, and both the nurse and housekeeping manager confirmed the lack of clear signage and PPE availability. Another resident received wound care and incontinent care without staff donning appropriate PPE, and staff interviews revealed uncertainty about which residents were on EBP. Hand hygiene practices were also deficient. During a skin assessment and peri-care for a resident with a stage three pressure ulcer, an LPN failed to change gloves after cleaning stool and before measuring the wound, resulting in potential cross-contamination. The LPN confirmed this lapse in practice during the interview. Additionally, infection tracking and monitoring were not accurately or timely maintained. The infection preventionist tracked infections using a color-coded mapping system, but failed to complete tracing for a month in which urinary tract infections (UTIs) had doubled, missing the opportunity to identify patterns and provide staff education or interventions. The facility also failed to provide updated policies and procedures for Legionella prevention and water safety. The maintenance manager and administrator were unable to provide documentation of water temperature checks, line flushing, or inspections, and the facility continued to operate under an outdated Legionella policy. Water testing revealed positive Legionella results in two areas, but the local health department was not notified, and required interventions such as flushing and retesting were delayed. The facility's policy required scheduled monitoring and a system approach to positive results, but these were not followed, as confirmed by staff interviews and policy review.
Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
The facility failed to notify the resident representative when a change in health status occurred for a resident with multiple diagnoses, including dementia, hypertension, and benign prostatic hyperplasia. The resident experienced symptoms such as altered mental status, emesis, fever, and diminished lung sounds, which led to new physician orders for laboratory tests, medications, and diagnostic imaging. Medical record review showed that while the nurse practitioner and physician were notified of the resident's condition changes and new orders were implemented, there was no documentation that the resident's family or representative was informed of these significant changes, including the addition of new medications and laboratory testing. Staff interviews confirmed that the assigned LPN did not notify the family of the new orders or the change in the resident's condition. The progress notes were silent regarding family notification during the period when the resident's health status changed and interventions were initiated. Additionally, the facility was unable to provide a change of condition policy when requested during the survey process.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for a resident admitted with Parkinson's disease, traumatic subdural hemorrhage, and bipolar disorder with psychotic features. Upon admission, the initial skin assessment did not document any areas of concern. However, a second skin assessment conducted three days later identified scattered bruising on both upper extremities, which was also noted in the progress notes. The family and physician were notified of the bruising, but there was no documentation of an investigation into the cause of the injuries at that time. During interviews, the resident reported feeling that staff were rough during mechanical lift transfers, though he had not reported this to staff. The DON was unaware of both the bruising and the resident's concerns until questioned by the surveyor, and the Unit Manager confirmed observing the bruising but did not document any investigation. The facility's policy requires investigation of all alleged violations, including injuries of unknown source, but this was not followed in this case.
Care Plan Failed to Reflect Resident Preference for Catheter Management
Penalty
Summary
The facility failed to ensure that the care plan for a resident with a suprapubic urinary catheter reflected the resident's preference for having catheter changes performed by the urologist in the physician's office, rather than in the facility. The resident, who had diagnoses including paraplegia, neurogenic bowel, chronic heart failure, chronic kidney disease, and neuromuscular bladder dysfunction, had a history of hospitalizations and follow-up appointments where the urologist changed the catheter in the office. Despite this, the resident's care plan and medical record did not document this preference, and facility orders continued to direct staff to change the catheter monthly on the night shift, with some orders being discontinued or unsigned without documentation of resident refusal. Interviews with the resident confirmed dissatisfaction with the facility's handling of catheter orders, and review of the care plan by the MDS RN verified that the resident's preference for in-office catheter changes was not addressed. The facility's policy required person-centered care planning, but the interdisciplinary team did not update the care plan to reflect the resident's wishes, resulting in a lack of alignment between the resident's preferences, physician orders, and the care provided.
Failure to Assist Resident with Denture Use and Oral Care
Penalty
Summary
A deficiency was identified when a resident with significant cognitive impairment and multiple medical diagnoses, including liver cell carcinoma, congestive heart failure, and depression, did not receive necessary assistance with activities of daily living (ADLs), specifically with oral care and denture use. The resident's care plan indicated a need for staff to assist with oral care and encourage denture use due to her full upper dentures and lack of lower teeth. Despite this, observations and interviews revealed that the resident was often without her dentures, impacting her ability to eat meals. The resident's daughter reported concerns that staff were not assisting her mother with her dentures, noting that she would often find her mother without them after breakfast. Multiple observations confirmed the resident did not have her dentures in, and during one meal, she was only able to eat sherbet because her dentures were not in place. A CNA interviewed was unaware the resident had dentures and relied on residents to inform her, acknowledging that confused residents may not communicate this need. The dentures were eventually located in the bathroom, but the lack of staff awareness and assistance resulted in the resident not having her dentures during meals.
Failure to Provide Adequate Activity Program for Residents
Penalty
Summary
The facility failed to provide an activity program that met the needs and preferences of its residents, as evidenced by the experiences of two residents reviewed. Both residents were cognitively intact and expressed that participating in group activities was very important to them. However, the activity calendar showed that facility-led activities were limited, with the last scheduled activity each day occurring at 2:00 P.M. and only one evening activity per week, which was resident-led and not inclusive of all residents. Interviews with the residents revealed dissatisfaction with the lack of activities in the late afternoon and evening, and that some resident-led activities were not open to everyone, leaving some residents feeling excluded. Staff interviews confirmed that the activities coordinator worked only until 4:00 P.M. and that evening activities were not facilitated by staff, nor was participation tracked. The activity leader acknowledged that there were not enough activities being conducted to meet residents' needs and that the current program did not align with the facility's policy to provide a program responsive to residents' interests and needs. Medical record and care plan reviews further indicated that the interventions for these residents primarily involved providing materials for independent activities upon request, rather than structured group activities as preferred by the residents.
Failure to Timely Assess, Document, and Treat Skin Impairments
Penalty
Summary
The facility failed to provide timely assessment, obtain appropriate treatments, clarify, and complete physician orders for three residents with skin impairments. For one resident with a history of dementia, hip dislocation, and incontinence, a new open area was discovered on the left buttock during incontinence care. Although the area was reported and assessed, there was a delay in initiating a physician order for wound treatment, which was not started until two days after the wound was first identified. Documentation showed the wound increased in size and developed drainage before treatment began. Another resident with dementia, altered mental status, and a history of skin cancer had unclear and conflicting treatment orders for wounds on the forehead. During wound care, an LPN applied only one of the two ordered ointments, and later admitted to not following the full order due to confusion about which ointment should be used. The treatment administration record was signed as if both treatments were completed, despite only one being applied. The DON confirmed that the orders were unclear and that documentation did not accurately reflect the care provided. A third resident with a history of cancer, malnutrition, and rheumatoid arthritis was observed with an undated dressing on the left forearm covering a scabbed area. The resident reported a recent bleeding incident, but there was no documentation in the medical record regarding the skin impairment, no skin assessment, and no physician notification or treatment order. Nursing staff and management were unaware of the new skin area, and facility policy requiring measurement and documentation of all skin areas was not followed.
Failure to Prevent Accidents and Incomplete Fall Investigations
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision or implement appropriate interventions to prevent accidents and falls for three residents. For one resident with dementia and a history of falls, the facility did not conduct comprehensive fall investigations or root cause analyses after multiple unwitnessed falls. Documentation lacked detailed evaluation of environmental or situational hazards, and there was no evidence of witness statements or thorough review of circumstances leading to the falls. Interventions were limited to frequent checks and keeping mobility aids within reach, without clear documentation of individualized or effective fall prevention strategies. Another resident, who was cognitively intact and had a history of CVA and mobility limitations, was injured when a CNA transported her in a wheelchair without foot pedals, resulting in the resident's foot becoming caught under the chair and causing pain to a previously injured knee. The CNA admitted to not using the foot pedals because the transfer was a short distance, and the incident was documented in the medical record. The facility provided education to staff and the resident after the incident, but the initial failure to use required equipment directly contributed to the accident. A third resident with multiple fractures and a history of falls experienced several falls during her stay, some resulting in head injuries and lacerations. Fall investigations for these incidents were incomplete, with documentation consisting of brief, unclear notes that did not allow for determination of the circumstances or contributing factors. The facility did not document root cause analyses, witness statements, or details such as the last time the resident was seen or toileted. The facility's fall management policy required comprehensive documentation, but this was not followed in practice, as confirmed by interviews with facility leadership.
Delay in Initiation of Prescribed Antibiotic for UTI
Penalty
Summary
A deficiency occurred when the facility failed to timely initiate prescribed antibiotic treatment for a resident diagnosed with a urinary tract infection (UTI). The resident, who had a history of dementia, altered mental status, benign prostatic hyperplasia with urinary symptoms, and was incontinent of bowel and bladder, exhibited changes in condition including nausea, vomiting, fever, and altered mental status. Laboratory tests and physician assessments led to an order for cefuroxime axetil 500 mg twice daily to treat the UTI. Despite the order being received and the medication being available in the on-site emergency medication dispensary, the antibiotic was not started as prescribed. Documentation shows that the order for cefuroxime was received, but administration did not begin until two days later. The delay was confirmed by review of the medication administration record, which indicated that the first dose was given two days after the order was received. Interviews with nursing staff and the DON confirmed that the medication should have been started immediately and that the system would default to the next scheduled dose if not manually adjusted. The facility's policy requires medications to be administered as prescribed, but this was not followed in this instance, resulting in a delay in treatment for the resident's UTI.
Failure to Administer Full Course of Prescribed Antibiotic for C-Diff
Penalty
Summary
A deficiency occurred when a resident with a history of liver cell carcinoma, congestive heart failure, and depression was admitted and subsequently diagnosed with Clostridioides Difficile (C-Diff). The physician ordered Vancomycin to be administered four times daily for seven days. However, the medication was not available from the pharmacy at the time the order was written, resulting in three missed doses at the start of the prescribed course. The order was not updated to reflect the actual start date of the medication, and the resident did not receive the full prescribed duration of antibiotics. Documentation shows that the resident began receiving Vancomycin only after a delay, and the missed doses were noted in the Medication Administration Record and nursing progress notes. The Director of Nursing confirmed that the resident did not receive the full course as ordered. The resident experienced a decline in condition, including increased lethargy and confusion, which led to hospitalization. Hospital records indicated a diagnosis of sepsis secondary to C-Diff and pancolitis.
Failure to Secure and Appropriately Store Medications
Penalty
Summary
Surveyors identified that the facility failed to ensure medications and biologicals were safely and appropriately stored, as required by professional standards. In three separate cases, medications were found unsecured in resident rooms, accessible to individuals without proper authorization or knowledge of their use. For one resident with multiple diagnoses including bipolar disorder, vascular dementia, and diabetes, an open, unlabeled bottle of antifungal powder was found on the bedside table, despite no physician order for its use. Nursing staff confirmed that the medication should not have been present in the room and that the resident did not have an order for it. Another resident with a history of cancer, pressure ulcers, and other complex medical conditions was found to have three containers of topical medication in their room, labeled with their name and application instructions. These medications were intended for wound care and were supposed to be administered by licensed personnel. Both the wound physician and unit managers confirmed that these medications should not have been left in the resident's room unsupervised, and the containers were subsequently removed by staff. A third resident, with diagnoses including dementia, Alzheimer's disease, and a history of hip dislocation, was also found to have an open, unlabeled bottle of antifungal powder on the bedside table. Nursing staff again verified that the medication should not have been in the room and that there was no physician order for its use. In all three cases, the facility failed to follow proper medication storage protocols, resulting in medications being accessible in resident rooms without appropriate oversight.
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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 Tipp City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Troy Rehabilitation And Healthcare Center | 4.4 mi | ★★★★★ | 18 | 0 |
| Momentous Health At Vandalia | 5.7 mi | ★★★★★ | 19 | 0 |
| Laurels Of Huber Heights The | 7.4 mi | ★★★★★ | 5 | 0 |
| Vancrest-upper Valley | 8.1 mi | ★★★★★ | 0 | 0 |
| Cypress Pointe Health Campus | 8.9 mi | ★★★★★ | 6 | 0 |
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