Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 The Springs At Wyandot Trail during CMS and state inspections, most recent first.
Surveyors found that during a morning med pass on one hall, RNs repeatedly left a medication cart laptop open with the electronic charting system visible and accessible while walking away to administer meds in resident rooms. A staff member confirmed the laptop remained open and unsecured even as a resident ambulated nearby. In interviews, an RN acknowledged not following the expected practice of minimizing the charting system and closing the laptop screen, and facility leadership confirmed there was no formal written policy on securing laptops when staff left the med cart, despite an expectation that screens be closed to prevent visibility.
A resident with atrial fibrillation, DM, TBI, lymphedema, and sleep apnea was cognitively intact but required substantial to maximal assistance with ADLs. Although the care plan called for assistance with safe completion of ADL tasks, there was no documentation of shaving or shaving refusals, and the resident stated staff had not helped him shave since admission. Observation showed long stubble on the face, and a CNA confirmed the resident had not been shaved.
Missing and Damaged Hearing Aids Not Addressed: A resident with documented hearing loss and intact cognition reported that her hearing aids were lost and believed to have been sent to laundry. One aid was later found damaged and did not work, while the second could not be located. Staff interviews showed the item was not tracked through a formal log, and key leaders were unaware of the missing and damaged hearing aids.
Inaccurate assessment of a resident’s pressure ulcer. A resident with functional quadriplegia, severe malnutrition, and skin breakdown had a right ischial wound repeatedly documented as an abrasion with changing measurements and descriptions, despite later hospital records showing a stage 2 pressure ulcer and facility staff later identifying the wound as a pressure injury with slough and visible subcutaneous tissue. The DON stated she did not routinely review wounds unless asked, and the MD relied on the ADHS for wound assessment.
Failure to Use Hoyer Lift During Transfer: A resident with repeated falls, generalized weakness, and dependence for transfers had a care plan requiring a Hoyer lift, but two staff members transferred the resident without it while going to the shower. The resident’s knees buckled, the resident was lowered to the floor, and the fall was documented without injury.
Medication Error Rate Exceeded 5 Percent: An RN made two medication errors during observed med pass, resulting in a 5.41% error rate. The RN did not prime an insulin pen before giving Lantus to a resident with DM2 and other significant diagnoses, and also mixed polyethylene glycol powder with 5 ounces of water instead of the 8 ounces listed on the package. The resident had a BIMS score of 15 and received insulin injections.
Failure to prime an insulin pen before administering Lantus to a resident with DM2 and other significant diagnoses. An RN gave 32 units of Lantus without performing the required safety test/priming step, and later confirmed she knew the pen should have been primed with 2 units before the ordered dose was dialed and given.
A resident with severe cognitive impairment, dysphagia, and dependence for care lost several teeth while eating, with scant bleeding noted and a detached bridge-like dental structure observed. A dental appt was scheduled, but the dentist could not complete the exam and referrals to other dentists were made. The chart lacked timely documentation of follow-up, and the resident’s rep did not receive clear communication about the outcome. Staff interviews showed confusion between transportation, nursing, and DHS about who was responsible for arranging the next dental visit.
Infection Control Lapse During Incontinence Care: Staff failed to follow infection control protocols during incontinence care for a resident with severe cognitive impairment, bowel and bladder incontinence, and dependence for toileting hygiene. During observed care, CNA and DON staff completed perineal care, brief changes, and repositioning, but CNA later confirmed gloves were not removed and hand hygiene was not performed after finishing care and before touching other items in the resident’s room.
Unsecured Electronic Charting System During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to maintain privacy and confidentiality of residents’ electronic medical records during medication administration on the 300 hall, affecting 12 identified residents. On 04/13/2026 at 9:47 A.M., an RN walked away from the medication cart while the laptop on the cart remained open with the facility’s electronic charting system visible and accessible to anyone in the immediate area. Shortly thereafter, another RN began using the same cart for medication administration and, at 9:52 A.M., entered a resident’s room to administer medications while leaving the laptop screen open in the hallway with the charting system visible. This observation was corroborated by a housekeeper who was present in the hallway at the time. At 9:55 A.M., the same RN returned to the cart, prepared medications for another resident, and before leaving again only minimized the charting system window, leaving the laptop open and unsecured while a resident was observed ambulating near the unattended cart. When the RN returned at 9:58 A.M., the laptop remained open and accessible. In an interview, the RN confirmed that the laptop had remained open and acknowledged that the expected practice was to minimize the charting system and fold the laptop screen down when stepping away, which was not followed. In a subsequent interview, the Administrator and DON confirmed that, although the expectation was for staff to minimize the charting system and close the laptop screen to prevent visibility, the facility did not have a formal written policy addressing laptop security when staff walked away from the medication cart.
Failure to Assist Resident With Shaving
Penalty
Summary
The facility failed to provide assistance with activities of daily living, including shaving, for one resident. Resident #55 was admitted with diagnoses including atrial fibrillation, diabetes mellitus, traumatic brain injury, lymphedema, and sleep apnea, and was found to be cognitively intact on the BIMS evaluation. The functional assessment showed the resident required substantial or maximal assistance with showering and bathing, and the baseline care plan included providing assistance to ensure safe completion of ADL tasks. However, the medical record contained no documentation of shaving or shaving refusals. During observation, the resident had long stubble on the face, and the resident stated he wanted to shave but needed assistance and that staff had not assisted him to shave since arrival. A CNA later confirmed the resident had long stubble on the face, and the job description for the Certified Resident Care Associate included shaving male residents.
Missing and Damaged Hearing Aids Not Addressed
Penalty
Summary
The facility failed to address a resident's hearing aids going missing and one being put through the laundry. Resident #3 was admitted with diagnoses including stage 2 chronic kidney disease, neoplasm of the colon, and depression, and her care plan identified hearing loss with interventions to use hearing aids as indicated and refer for hearing-related services as needed. Her significant change assessment documented a BIMS score of 15 out of 15 and noted adequate hearing with the use of hearing aids. Resident #3 reported that she could not locate her hearing aids and believed they may have been sent to laundry. She stated that one hearing aid was found by laundry staff after being washed, but it was stretched out and did not work, and the second hearing aid could not be located. Staff interviews showed the laundry process for personal items relied on staff noticing and reporting items that were not supposed to be laundered, but the ESA stated she was very busy and often only did a quick pat down of clothing. The ESS and Director of Social Services had no knowledge of the missing or damaged hearing aids, and the Administrator stated she was responsible for follow-up on missing item reports; however, the missing item log had no reported concerns related to Resident #3's hearing aids.
Inaccurate Assessment of a Resident’s Pressure Ulcer
Penalty
Summary
The facility failed to accurately assess and document a pressure ulcer for a resident with functional quadriplegia, severe protein-calorie malnutrition, lymphedema, and existing skin breakdown. The resident’s right ischial tuberosity wound was documented over time as an abrasion with varying measurements and descriptions, including red, pink, yellow, and epithelial tissue, but the record did not reflect an accurate pressure injury assessment during that period. The resident’s MDS showed dependence on staff for showers, toileting hygiene, and lower body dressing, and the resident was identified as at risk for pressure ulcers. The wound later appeared worse during observation, with red tissue, a dime-sized opening with yellow exudate, and visible subcutaneous tissue after the exudate was removed. The Assistant Director of Health Services stated the wound had been documented as an abrasion but was now a pressure injury, and later stated it was an unstageable pressure injury because slough was present. Hospital records reviewed by the facility showed the resident had a stage 2 pressure ulcer at the right ischial tuberosity during a prior hospitalization, and the resident stated the wound had been present for a long time and kept reopening. The facility’s wound policy required weekly measurement and documentation of wound characteristics, including length, width, depth, exudate, color, odor, margins, surrounding tissue, and tunneling or undermining when applicable.
Failure to Use Hoyer Lift During Resident Transfer
Penalty
Summary
The facility failed to use a Hoyer lift during a transfer for Resident #15, despite the resident’s care plan specifying dependent assist with a Hoyer lift for transfers. Resident #15 had diagnoses including repeated falls, need for assistance with personal care, and generalized muscle weakness. The MDS showed the resident was cognitively intact and dependent for bed mobility, sit-to-stand, chair/bed-to-chair transfer, and toilet transfer. On 03/29/26, Resident #15 fell while being transferred to the shower. The resident was being transferred by two staff members without use of the Hoyer lift, and the resident’s knees buckled, requiring staff to lower the resident to the floor. The resident complained of pain rated 5/10 at the time of the fall, and the fall was documented as without injury. The IDT note and interviews confirmed that the resident required a Hoyer lift for transfers at the time of the fall, and the Director of Health Services confirmed the lift was not used.
Medication Error Rate Exceeded 5 Percent
Penalty
Summary
The facility failed to ensure the medication error rate did not exceed 5 percent. Based on observation, record review, staff interview, and review of insulin pen directions, the facility had two medication errors out of 38 opportunities for an error rate of 5.41%. This involved one resident out of four residents observed for medication administration, with a facility census of 44 residents. The resident had diagnoses including encounter for orthopedic aftercare following surgical amputation of the right toe, osteomyelitis, sepsis due to methicillin susceptible staphylococcus aureus, cellulitis of the right lower limb, type 2 diabetes mellitus with foot ulcer, constipation, hypertension, and hyperlipidemia. The resident’s MDS showed a BIMS score of 15, indicating no cognitive impairment, and the resident received insulin injections. During observation of medication administration, an RN gave Lantus Solostar U-100 insulin 32 units to the resident’s left lower abdomen without priming the insulin pen. The same RN also administered polyethylene glycol 3350 powder 17 grams in five ounces of water. During interview, the RN verified she did not prime the Lantus pen before administration and stated she knew the pen must be primed with two units of insulin before giving the prescribed dose. She also stated she gave the polyethylene glycol powder in five ounces of water instead of the full eight ounces stated on the package. The Lantus instruction leaflet stated to always perform the safety test before each injection by selecting two units, holding the pen with the needle upward, tapping the reservoir to move air bubbles, and pressing the injection button until insulin comes out and the dose window shows 0.
Failure to Prime Insulin Pen Before Administration
Penalty
Summary
The facility failed to prevent a significant medication error when an RN administered Lantus Solostar U-100 insulin to Resident #11 without priming the insulin pen before the injection. Resident #11 was admitted on 04/02/26 with diagnoses including type two diabetes mellitus with foot ulcer, osteomyelitis, sepsis due to methicillin susceptible staphylococcus aureus, cellulitis of the right lower limb, and other conditions. The resident’s MDS showed a BIMS score of 15, indicating no cognitive impairment, and the resident received insulin injections. An order dated 04/03/26 directed Lantus Solostar U-100 insulin 32 units subcutaneously once daily. During observation on 04/14/26 at 8:36 A.M., RN #625 administered 32 units of Lantus to the resident’s left lower abdomen and did not prime the insulin pen prior to administration. In interview at 8:43 A.M., RN #625 confirmed the pen was not primed and stated she knew the Lantus pen must be primed with two units of insulin before dialing the prescribed dose. The Lantus Solostar pen instructions reviewed by surveyors stated to always perform the safety test before each injection by selecting two units, holding the pen with the needle pointing upward, tapping the reservoir to move air bubbles toward the needle, and pressing the injection button until insulin comes out of the needle tip.
Delayed Dental Follow-Up After Tooth Loss
Penalty
Summary
The facility failed to ensure a resident received necessary and timely dental services after the resident lost several teeth while eating lunch. The resident had diagnoses including acute and chronic respiratory failure, type 2 diabetes mellitus, dysphagia, need for personal assistance with care, and unspecified dementia, and was documented as having severe cognitive impairment. The resident was dependent for self-care and mobility, used a wheelchair, and was noted in the care plan to be at risk for malnutrition related to being edentulous with only a full upper denture. After the resident lost the teeth, the mouth was examined and scant bleeding was noted, and the teeth were described as resembling a bridge that had become detached. A dental appointment was scheduled, and the resident was transported to the appointment, but the dentist was unable to examine the resident and referrals to other dentists were made. The medical record did not document follow-up of the dental appointment for several weeks afterward, and the resident’s representative reported not receiving communication about the outcome or follow-up until speaking with the facility driver. Staff interviews showed confusion and gaps in communication about the dental referral process and follow-up. The transportation associate stated the resident did not receive discharge paperwork and that the referrals were supposed to call to arrange the next appointment, while nursing staff expected follow-up information to be relayed after the appointment. The Director of Health Services stated the dental follow-up documented in the record was not timely and that the appointment follow-up was timely because referrals were contacted sooner than the documentation reflected, but the record did not contain documentation supporting that follow-up.
Infection Control Lapse During Incontinence Care
Penalty
Summary
The facility failed to ensure staff followed infection control protocols during incontinence care for one resident. Resident #5 was admitted with diagnoses including acute and chronic respiratory failure, type 2 diabetes mellitus, urinary tract infection, need for personal assistance with care, and unspecified dementia. The resident’s BIMs showed severe cognitive impairment, and the MDS indicated the resident used a wheelchair for mobility and was dependent for toileting hygiene. The resident was always incontinent of bowel and bladder and had not had a trial of a toileting program. The care plan noted episodes of incontinence related to immobility and impaired cognition. During observed incontinence care, the Director of Health Services and CNA #521 performed hand hygiene and donned gloves, then completed perineal and rectal cleansing, removed the soiled brief, applied a new brief, and provided barrier cream and repositioning. After the barrier cream was applied, the Director of Health Services removed gloves, performed hand hygiene, and put on new gloves, while CNA #521 continued to reposition the resident, secure the brief, attach the call light, place pants, pull the resident up in bed, reposition the resident onto the left side, float the heels, adjust covers, and lower the bed. CNA #521 later confirmed that gloves were not removed and hand hygiene was not performed after completing incontinence care and before touching other items in the resident’s room.
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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 Lancaster
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lanfair Center For Rehab & Nsg Care Inc | 1.4 mi | ★★★★★ | 0 | 0 |
| Main Street Terrace Care Center | 1.7 mi | ★★★★★ | 14 | 0 |
| Buckeye Care And Rehabilitation | 2.1 mi | ★★★★★ | 23 | 0 |
| Luxe Rehabilitation And Care Center | 3.5 mi | ★★★★★ | 3 | 0 |
| Arbors At Carroll | 4.5 mi | ★★★★★ | 8 | 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 July 2026) and official state health department websites.