Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Violet Springs Health Campus during CMS and state inspections, most recent first.
Failure to Provide Routine Bathing and Grooming Assistance: A resident who preferred showers did not receive scheduled showers and instead received partial bed baths, while two other dependent residents were observed with unshaven facial hair, uncombed or unclean hair, dirty fingernails, soiled clothing, and other signs of missed personal care. Staff interviews and record review confirmed the residents required assistance with ADLs and grooming, but the expected bathing and hygiene care was not consistently provided.
Respiratory care was not provided as ordered for one resident who was observed without prescribed continuous O2, including outside the room, and an LPN confirmed the resident was not given O2 in therapy, the dining room, or at the nurse's station. The facility also had a resident using a c-pap machine without a physician order, and two other residents had nebulizer masks and tubing left uncovered on their nightstands; the DON and an LPN verified these observations.
The facility failed to keep resident medical records complete and accurate for four residents by omitting diagnoses from the face sheet/diagnosis pages despite hospital records listing multiple conditions, including HTN, dementia, CKD, cancer, CAD, AFib, CHF, COPD, and Parkinson’s disease. The facility also inaccurately documented a resident’s bilateral LE wound treatment time on the TAR, recording it as completed earlier than when an LPN observed the care being performed; the DON verified the time entry was inaccurate.
Two residents did not receive adequate nutrition and hydration support when one resident with severe protein malnutrition and significant weight loss, who was care planned for increased caloric intake, reported not receiving ordered double portions and was observed receiving only single portions, while another dependent resident at risk for malnutrition, requiring tray setup and assistance with meals, was repeatedly observed with meal trays and fluids placed out of reach, struggling to cut food and with covered items and rolled silverware left unopened, not consistently offered snack items or alternate foods when he disliked the main entrée, and lacking a reliable hydration process despite staff acknowledging there was no hydration policy and that water was mainly given to residents who could request it.
Failure to Provide Bathing per Resident Preference: A resident who preferred showers was not bathed according to her stated preference. Her care guide called for showers twice weekly, but documentation showed she received partial bed baths instead and had not been given a shower since admission. The resident said she wanted routine bathing, and an LPN confirmed she had received three partial baths and preferred showers.
Failure to obtain a physician order and complete required restraint assessments for a resident using a trunk/seatbelt restraint. The resident had epilepsy, mood disorder, expressive language disorder, convulsions, osteoporosis, and moderately impaired cognition, and the care plan identified the seatbelt as a physical restraint because the resident could not independently release it. Record review showed no restraint assessments and no order for the restraint, which the DON confirmed.
A resident with Alzheimer's disease, dementia, major depressive disorder, and anxiety received an open-ended PRN Xanax order that was not limited to 14 days. Nursing notes described restlessness, anxiousness, wandering, and poor sleep, while the NP documented the resident's chronic anxiety as stable and continued standing meds without documenting a rationale or duration for the PRN Xanax. The DON confirmed the PRN psychotropic order lacked the required stop date and supporting documentation.
Failure to Offer Preferred and Group Activities: Two residents with severe cognitive impairment had documented interests in music, reading, pets, news, and religious services, but records showed only generic activity packet participation and no evidence they were invited to or attended group activities. One resident was observed awake with no entertainment and stated she loved country music, while staff confirmed there was no way to play it in her room despite available smart speakers. The other resident was observed sleeping while activities were occurring elsewhere, and the LEC verified there was no evidence he had been offered or declined group activities.
Failure to Provide Ordered Skin and Wound Care Two residents did not receive ordered skin and wound treatments as documented. One resident with facial dryness and rash had ordered topical creams for the beard/face area, but the resident reported the treatments were often missed and an RN admitted signing the TAR without actually applying the creams. Another resident with bilateral venous ulcers had ordered daily leg wound care and wraps, yet repeated observations showed no dressings or ace wraps in place, and an LPN confirmed the treatment was only being done at the time of observation.
Two residents had pressure ulcer care failures. One resident with multiple chronic conditions and documented risk for skin breakdown developed a worsening right heel injury despite ordered preventive measures, and surveyors observed the resident sitting with legs down and no pressure-relieving boot in place. Another resident was admitted with pressure ulcers to the coccyx and left heel, but surveyors observed no off-loading to the Stage III heel ulcer while the resident wore street shoes and later lay in bed without heel protection.
An LPN made multiple medication administration errors during a morning pass, including applying a Lidocaine patch to the wrong body area and to a resident who denied pain, initially giving the wrong resident's medications, and omitting a scheduled Probiotic while documenting it as given on the eMAR. The resident questioned the medications and the nurse later confirmed the errors, including confusion caused by room layout and medication packets containing meds for the wrong time of day.
Bedside Storage of Medications Without Orders Two residents had medications left on bedside tables without documented self-administration assessments or orders allowing bedside storage. One resident with COPD, chronic respiratory failure, and moderate cognitive impairment had a PRN inhaler at bedside, and another resident with multiple medical conditions and moderate cognitive deficit had a nasal spray at bedside. An LPN verified both medications were stored improperly.
Vegetarian Diet Menu Not Followed: A resident with dementia and a physician order for a regular vegetarian diet did not receive the entree items listed on the lunch menus and instead was served only side items on multiple occasions. The Food Services Director verified the resident did not receive the entree, while the POA expected full meals and staff acknowledged there was no vegetarian menu even though meat-free options were available.
Failure to provide ordered diet texture and liquids for two residents. One resident with Parkinson’s disease and aspiration risk was ordered soft and bite-sized foods with moderately thick liquids, but was observed receiving toast, whole sausage patties, and thin coffee and water, while the tray ticket still showed a regular diet. Another resident with dysphagia, PEG history, and multiple orthopedic injuries was ordered mechanical soft with thin liquids and no bread, but was served a dinner roll; staff were unaware of the no-bread order, and the Administrator said the meal ticket system could print an outdated diet if the update was not selected.
A resident with an indwelling urinary catheter had the catheter bag observed on the floor, and another resident with pressure ulcers received wound care in which an LPN changed gloves without hand hygiene and did not wear the ordered EBP PPE. The resident with wounds had a coccyx pressure ulcer, a left heel pressure ulcer, and a Braden score indicating risk for skin breakdown, while facility policy required handwashing between glove changes and EBP for residents with chronic wounds or indwelling devices.
Call Light Not Kept Within Reach for a Resident in Recliner: A resident with severely impaired cognition, dementia, and fall risk was repeatedly observed sitting in a recliner with no call light within reach, while the call light remained across the room near the bed. An RCA confirmed the resident spent most of her time in the recliner, had no way to call for staff, and the wall call light did not reach her chair; the resident also had no pendant or extended cord.
A resident's family reported a missing lamp, which was removed from the room by staff and later found in the maintenance office. The facility did not document or address the grievance in accordance with its policy, and there was no evidence of a timely investigation or resolution.
A resident with multiple cardiac and neurological conditions experienced a fall, persistent vomiting, and hypotension. Despite a CNP's order for IV fluids and other interventions, staff delayed initiating the IV for approximately eight hours and did not obtain a urinalysis. The resident's condition deteriorated throughout the day, culminating in unresponsiveness and the need for CPR, with the resident later passing away at the hospital. The deficiency was due to staff failing to recognize and respond promptly to an acute change in condition.
A resident with multiple medical conditions and impaired cognition, identified as being at risk for falls, was found on the floor after attempting to self-transfer while wearing regular socks instead of non-skid footwear. An LPN confirmed the resident was not provided with the required fall prevention intervention, which was specified in the care plan and facility policy.
The facility did not ensure annual performance reviews for STNAs, affecting all residents. An STNA hired in May had a 90-day evaluation but no annual appraisal by October. Business Office Staff and the administrator confirmed the absence of the required evaluation.
The facility did not ensure that an STNA completed the required 12 hours of in-service training annually. The STNA, hired earlier in the year, completed only six hours of orientation training and did not finish the assigned 12 hours of in-service or online training. This oversight was confirmed by staff interviews and had the potential to impact all residents.
The facility failed to date multi-use vials of tuberculin PPD when opened, as observed in the medication room. Three open and unlabeled vials were found, confirmed by the DON. The facility's guidelines require dating and initialing vials upon opening, with a 30-day usage limit. This oversight potentially affected 30 new admissions.
The facility failed to monitor and administer blood pressure medication correctly for two residents. One resident did not have her blood pressure checked daily as required for her as-needed hydralazine prescription. Another resident received hydralazine despite her blood pressure being below safe parameters, and the physician was not notified. Staff confirmed that the medication should have been held and the physician informed.
A resident at risk for falls due to multiple medical conditions did not have a care planned fall mat present in their room, as observed during a survey. Despite being severely cognitively impaired and requiring assistance with ambulation, the fall mat intervention was not implemented, as confirmed by staff and the DON.
The facility failed to ensure timely review and action on pharmacy recommendations for three residents. A resident had multiple pharmacy recommendations without documented physician response dates. Another resident's recommendation to discontinue Tramadol was not acted upon, leaving the medication order active. The DHS confirmed the lack of timely documentation and action.
The facility failed to provide proper parameters for medication administration, affecting several residents. A resident with cognitive impairment had hydralazine administered without blood pressure monitoring, while another resident received pain medications without clear guidelines. The DHS confirmed the absence of necessary parameters for these medications.
A facility failed to maintain a medication error rate of five percent or less, resulting in a rate of 5.77 percent. An LPN improperly administered a duloxetine delayed-release capsule by opening it and mixed its contents with applesauce, and crushed a prednisone tablet listed on the Do Not Crush list. The DON confirmed these actions were against proper medication protocols.
Failure to Provide Routine Bathing and Grooming Assistance
Penalty
Summary
The facility failed to ensure that residents who were dependent on staff received appropriate grooming and routine bathing. The report identified four affected residents, including one resident who preferred showers but did not receive them as scheduled, and three residents who were dependent on staff for personal hygiene and grooming needs. The findings were based on record review, observations, interviews, and facility policy review. One resident was admitted with diagnoses including hypertension, hyperlipidemia, severe tricuspid regurgitation, cardiomegaly with aortic arch calcifications, purulent cellulitis of the left lower extremity, atrial fibrillation, and CHF. Her admission assessment showed that bathing preferences were important to her and that she preferred showers. Her care guide directed showers every Wednesday and Saturday, but review of shower documentation showed only partial bed baths on multiple days and no shower since admission. The resident stated she had not had a shower since admission and wanted routine bathing. An LPN confirmed she had received three partial baths and should have had two scheduled showers. Facility policy stated bathing should occur at least twice a week unless resident preference stated otherwise. Another resident was admitted with acute respiratory failure, COPD, atherosclerotic heart disease, severe morbid obesity, and other diagnoses. His care plan showed he required staff assistance with self-care and mobility, including shaving and grooming interventions on shower days. Observations showed several days of facial hair growth on multiple occasions, and staff confirmed he had not been shaved. A CNA stated residents are shaved when showers are provided and as needed, but she had not tried to shave him. The DON acknowledged the resident had long facial hair and had not been assisted with removal of unwanted facial hair according to his preference. A third resident with a history of cerebral infarction, dementia, diabetes, cerebellar stroke syndrome, and muscle weakness was dependent on staff for all ADLs, including showering and personal hygiene. Observations showed white dried flakes on his shirt, an odor of urine in his room, long fingernails with dirt underneath them, and cranberry juice stains on his shirt and blanket. The ADHS verified these conditions during observation. The report also cited the job description for a certified resident care associate, which included assisting with personal care such as keeping the resident dry and assisting with nail care.
Respiratory Care Orders Not Followed and Equipment Left Uncovered
Penalty
Summary
Safe and appropriate respiratory care was not provided for a resident who was receiving oxygen therapy. The resident had diagnoses including acute respiratory failure and COPD, and the admission assessment indicated oxygen use. A physician order dated 01/12/26 directed oxygen at 3 liters per nasal cannula continuously and to monitor for shortness of breath, restlessness, fatigue, rapid breathing, elevated heart rate, and worsening conditions. However, on 01/12/26 at 10:26 A.M. and again at 12:40 P.M., the resident was observed without oxygen in place, including while sitting at the nurse's station. The resident's record also showed a plan of care addressing shortness of breath related to COPD and acute respiratory failure with hypoxia, with interventions to administer oxygen per physician orders and as needed. During interview at 3:45 P.M., an LPN verified the resident was not provided oxygen outside of the room while in therapy, the dining room, and while sitting at the nurse's station. The observations and interview showed the resident was not receiving oxygen as ordered. The facility also failed to ensure proper handling of respiratory equipment for other residents. One resident using a c-pap machine had no physician order for its use, and the DON verified there was no order and that the mask was not stored in a protective covering. Two other residents had nebulizer face masks and tubing uncovered and lying on their nightstands, and an LPN verified those observations. One of those residents had an order for ipratropium-albuterol nebulizer treatments three times daily, and the other had an order for the same medication every six hours as needed.
Incomplete medical records and inaccurate treatment documentation
Penalty
Summary
The facility failed to ensure the medical records for Resident #86, Resident #88, Resident #91, and Resident #93 reflected their diagnoses. Resident #86 was admitted with diagnoses listed in the hospital discharge summary including hypertension, dementia, and chronic kidney disease, but the face sheet and diagnosis page in the electronic medical record did not indicate any diagnoses. Resident #88 was admitted with diagnoses including esophageal adenocarcinoma, coronary artery disease, anxiety, and gastroesophageal reflux disease, but his face sheet and diagnosis page also did not list diagnoses. The DON verified that both residents’ records were missing diagnoses. Resident #91’s electronic medical record likewise had no diagnoses readily available on the face sheet, despite the hospital summary listing diagnoses including hypertension, hyperlipidemia, prediabetes, severe tricuspid regurgitation, cardiomegaly with aortic arch calcifications, purulent cellulitis of the left lower extremity, atrial fibrillation, and congestive heart failure. The DON verified the record had no diagnoses readily available. Resident #93’s record contained diagnoses including acute respiratory failure, COPD, atherosclerotic heart disease, severe morbid obesity, right bundle branch block, bifascicular block, ventricular tachycardia, gout, Parkinson’s disease, benign prostatic hyperplasia, hyperlipidemia, hypothyroidism, constipation, and prediabetes, and the resident was documented as alert with impaired daily decision making on admission. The facility also failed to document Resident #91’s treatment time accurately. The resident had orders for daily bilateral lower extremity wound care, and the TAR documented the treatment as completed at 11:00 A.M. as a late entry. However, an LPN observed the wound care being completed at 3:45 P.M., and at that time the resident had no dressing or ace wraps on the bilateral lower extremities. The DON verified that the documented time of 11:00 A.M. was inaccurate.
Failure to Provide Ordered Double Portions, Meal Assistance, and Hydration
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate nutrition as ordered for one resident and insufficient meal assistance and hydration for another. One resident with multiple complex diagnoses, including severe protein malnutrition and significant weight loss, had a care plan indicating increased caloric and nutrient needs and physician orders for an appetite stimulant and nutritional supplement. This resident reported she was supposed to receive double portions at meals but stated she did not receive them. During a breakfast observation, she had a cinnamon bagel with cream cheese and two servings of cereal, and she stated she preferred a different cereal. At lunch, she was served a single portion of chicken and dumplings soup, carrots, and Jello; the Executive Director confirmed she was not given double portions and that her meal ticket did not indicate a double-portion order. The second resident had diagnoses including dementia, cerebrovascular disease, diabetes, and muscle weakness, and was care planned as at risk for malnutrition with interventions to assist with meals, offer alternate food and beverages as needed, and provide diet and supplements as ordered. The MDS showed the resident required tray setup for eating and was dependent on staff for all ADLs, with no documented refusals of care. Meal percentage records showed no morning or bedtime snacks documented over a two-week period, despite a facility policy stating a nourishing bedtime snack would be provided. Observations over several days showed the resident receiving meals such as hot dogs and ham but struggling to cut food, with covered fruit cups and rolled silverware left unopened, and staff not consistently assisting with setup or cutting food as needed. Multiple observations documented that this resident’s meal trays and fluids were frequently placed out of reach and not adjusted so he could eat or drink independently. On several occasions, he was seen semi-lying or lying in bed with the tray to the side and out of reach, or in a dining area without fruit or water available, and his water cup was observed empty and pushed against the wall out of reach. Staff interviews revealed that dietary staff sometimes waited to see if residents would open their own items before assisting, and CNAs reported they gave water primarily to residents who could ask for it and that there was no water cart. The Assistant Director of Health Services confirmed the expectation that trays should be placed in front of residents and food cut up if needed, and also confirmed there was no facility hydration policy, while the Director of Health Services stated all residents are offered a bedtime snack. The resident reported he did not like hot dogs and was not offered an alternative, despite facility policy requiring an appropriate alternate when food is not accepted and substitutions for residents consuming 75% or less, and staff were expected by policy to assist individuals as needed.
Failure to Provide Bathing per Resident Preference
Penalty
Summary
The facility failed to ensure that Resident #91 was bathed according to her stated preference. On admission, the resident’s life enrichment assessment documented that it was very important to her to choose the type of bath she received, and she indicated a preference for showers. Her care guide also directed that she was to receive showers on Wednesdays and Saturdays. Review of the shower documentation showed that from admission through 01/13/26, the resident received partial bed baths on 01/09/26, 01/11/26, and 01/13/26, and had not been provided a shower since admission. During interview, the resident stated she had not had a shower since admission but wanted routine bathing. An LPN later confirmed that the resident had received three partial baths since admission and that she preferred showers. The resident’s diagnoses included hypertension, hyperlipidemia, prediabetes, severe tricuspid regurgitation, cardiomegaly with aortic arch calcifications, purulent cellulitis of the left lower extremity, atrial fibrillation, and CHF.
Failure to Obtain Order and Assess Restraint Use
Penalty
Summary
The facility failed to regularly assess and obtain a physician order for a restraint for one resident. Resident #8 was admitted with diagnoses including epilepsy, unspecified mood disorder, expressive language disorder, unspecified convulsions, and age-related osteoporosis, and the quarterly MDS assessment indicated moderately impaired cognition and daily use of a trunk restraint. The care plan revised 11/17/25 identified that the resident was requesting a seatbelt to the wheelchair, described it as a physical restraint because the resident was unable to independently release it when in the chair, and included interventions such as using the seatbelt in the motorized wheelchair for safety and positioning. Review of the resident’s record from 01/01/25 to 01/14/26 revealed no restraint assessments, and review of physician orders on 01/14/26 showed no order for the restraint. The DON confirmed during interview on 01/14/26 at 9:50 A.M. that the resident did not have an order for the restraint and had not been assessed in the last year. The facility policy, "Guidelines for Restraint/Enabler use," required an individualized nursing observation on admission, quarterly, and as needed, and required an order specifying the type of restraint or enabler and the reason for use.
Open-Ended PRN Psychotropic Order Without Required Duration
Penalty
Summary
The facility failed to ensure that psychotropic medications ordered on an as needed basis were limited to 14 days unless the prescriber documented a rationale in the medical record and indicated the duration of the PRN order. This deficiency affected one resident who had diagnoses of Alzheimer's disease, dementia, major depressive disorder, and anxiety disorder. The resident was seen by the nurse practitioner after a hospitalization for a pulmonary embolism, and her severe Alzheimer's dementia with anxiety was described as stable while she continued receiving Buspirone, Duloxetine, and Remeron without medication adjustments. Nursing notes documented that the resident was restless and anxious, walked toward exit doors and into other residents' rooms, was not always redirectable, walked without her walker, and had difficulty sleeping. On 10/30/25, she was ordered Xanax 0.25 mg twice daily PRN, and the order remained open ended without an initial 14-day stop date. The PRN Xanax order was later resumed and then reordered again as Xanax 0.25 mg every 12 hours as needed, also without a specific duration. The nurse practitioner documented the resident's chronic anxiety as stable and listed her standing medications, but did not document a rationale for continuing Xanax PRN or indicate how long it should be used. The DON confirmed the PRN Xanax order did not include the required 14-day stop date and that the medical record lacked documentation supporting extension of the PRN use.
Failure to Offer Preferred and Group Activities
Penalty
Summary
The facility failed to provide preferred independent activities to two residents and failed to provide evidence that they were invited to or attended group activities. Resident #49 had diagnoses including unspecified mood disorder, pulmonary fibrosis, hypothyroidism, depression, anxiety, dementia, and hypertension, and her MDS showed severely impaired cognition. Her life enrichment assessment identified important interests such as listening to country music, being around animals, keeping up with the news, doing things with groups, participating in religious services, and reading books, newspapers, or magazines, along with favorite activities including bowling, cooking, reading, and coloring. Her care plan included inviting and assisting her to activities and reviewing the campus schedule with her, but activity documentation from 12/14/25 to 01/14/26 only showed participation in a generic activity packet, mindful moments sensory programming once, and a visitor, with no evidence she was provided music or other preferred activities and no activities declined. Observations on multiple dates showed her awake in her recliner with no entertainment, and she stated she loved country music. Staff confirmed there was no method in her room to play country music, although the facility had smart speakers available. Resident #86 had diagnoses including hypertension, dementia, and chronic kidney disease, and his BIMS showed severely impaired cognition. His life enrichment assessment identified interests in books, pets, news, and religious services. Activity documentation from 01/02/26 to 01/14/26 showed participation in a generic activity packet six times, with notes not specific to him, plus visitors and a visit from the life enrichment director, and no activities were declined. Observations showed him sleeping at a dining room table while activities were occurring in another area. The life enrichment director stated activity aides were to ask residents in the morning if they were interested in the day’s activities and verified there was no evidence Resident #86 had been offered or had declined group activities. The facility policy stated residents were to be invited to activities and offered structured and individual programs, with alternatives for meaningful leisure interests if they preferred not to participate in structured programs.
Failure to Provide Ordered Skin and Wound Treatments
Penalty
Summary
The facility failed to ensure a resident with non-pressure skin conditions received wound and skin treatments as ordered. Resident #65, who had diagnoses including Parkinson’s disease, tremors, osteoarthritis, anxiety, and depression, had physician orders for Betamethasone Dipropionate cream twice daily and Ketoconazole cream twice daily to the beard area until resolved. The record showed the resident developed a facial rash and dry, flaky skin, and the resident reported that staff were supposed to wash his face and apply medicated cream twice daily but that it did not always happen and was usually done only once a day. During interview, the resident stated he often had to ask for the treatment to be completed. The RN interviewed about the treatment administration record could not explain where the Betamethasone Dipropionate cream was being applied because the order did not specify a location, yet she had signed the TAR as if the treatment had been completed. She also acknowledged she did not apply the Betamethasone Dipropionate cream that morning despite signing it off, did not recall applying it the day before, and admitted she did not apply the Ketoconazole cream as ordered earlier that day despite documenting that she had. The facility also failed to provide ordered treatment to another resident with bilateral venous ulcers. Resident #93, admitted with acute respiratory failure, COPD, morbid obesity, and other diagnoses, had orders to cleanse both lower extremities, apply xeroform to open wounds, pad heels and weeping areas, and wrap the legs with Kerlix and ace wraps daily and as needed. Survey observations on multiple occasions showed the resident’s legs had no treatment or ace wraps in place, and an LPN confirmed the twice-daily treatment was only being completed at the time of observation and that the resident had no dressing or ace wraps on the bilateral lower extremities at that time. The TAR also reflected the treatment as completed later than the time it was observed.
Pressure Ulcer Care and Off-Loading Not Ensured
Penalty
Summary
The facility failed to identify, assess, and implement interventions to prevent pressure ulcers for one resident and failed to ensure pressure relieving interventions were in place for another resident. For the first resident, the record showed admission with multiple chronic conditions including heart failure, pulmonary fibrosis, COPD, hypothyroidism, osteoporosis, anxiety disorder, and dementia with moderate cognitive impairment. The care plan identified the resident as at risk for skin breakdown and included interventions such as turning and repositioning, floating heels, pressure reducing surfaces, and weekly skin assessments. Despite these measures being documented, the resident developed progressive right heel skin changes that were first documented as redness and later worsened to a dark red to black area and then an unspecified ulcer. The record also showed no documented refusals of the ordered preventive care during the months reviewed. Observations and interviews showed the resident sitting with legs down and no pressure relieving boot on the right heel, and later sitting in a wheelchair with legs down and no boot in place. The Assistant Director of Health Services stated the heel had been red and then became black and worsened, and that she was not sure when the pressure injury occurred. She also stated she was not wound certified and recommended wound clinic evaluation because the interventions had failed and the heel was getting worse. The Director of Health Services stated she did not see the heel until later in the course, that the facility did not have a wound NP, and that the NP and physician had probably not seen the wound. The NP stated she was not aware the resident had any pressure ulcers or injuries at that time. For the second resident, admission documentation showed existing pressure ulcers to the coccyx and left heel, with a Braden score of 15 indicating risk for skin breakdown. The care plan included wound care, dietary consultation, pressure reducing surfaces, and weekly skin assessment and measurement. However, observations showed the resident wearing street shoes on the left heel with no off-loading to the Stage III pressure ulcer, and later lying in bed with no off-loading to the left heel. An LPN verified there was no off-loading in place. The facility policy reviewed by surveyors stated residents should be evaluated for the need for pressure reduction surfaces and heel floats or boots, but the observed care did not show the left heel pressure ulcer was being off-loaded.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure its medication error rate did not exceed 5%, with two errors identified out of 30 opportunities for a medication error rate of 6.6%. The deficiency involved one resident, who was reviewed during a medication administration observation, and the errors were verified by the nurse involved. The resident had diagnoses including dorsalgia and had an order for Lidocaine 4% patch to be applied topically once daily as needed for the right ribs, along with a daily Probiotic Formula capsule scheduled between 6:00 A.M. and 10:00 A.M. During the morning medication pass, the LPN initially pulled medications for one resident and approached the wrong resident in a semi-private room. She applied a Lidocaine 4% patch to the resident's right lower back even though the resident denied pain and the order was for the right rib area on an as-needed basis. She then gave the resident a cup of pills, but the resident questioned the absence of Preservision Areds, which led the nurse to realize she had brought medications for the other resident in the room. The nurse then placed the medication cup aside and retrieved the correct resident's medications. When the nurse returned with the correct resident's medications, she again approached the wrong resident before correcting herself and giving the medications to the intended resident. The resident voiced concern about being given the wrong medications and asked what would happen if a cognitively impaired resident could not question the medications. Review of the record showed the resident's Probiotic was initialed as given on the eMAR even though it had not been administered during the earlier pass, and the nurse later confirmed it had been omitted and found in the bedtime medication packet. The facility policy required the five rights of medication administration and resident identification before medications were given.
Bedside Storage of Medications Without Self-Administration Orders
Penalty
Summary
The facility failed to ensure medications were not kept at bedside without orders for two residents. Resident #43 had diagnoses including chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia and hypercapnia, morbid obesity, anxiety disorder, cellulitis of the abdominal wall, type 2 diabetes mellitus with chronic kidney disease stage 3, hypertensive heart disease, and shortness of breath. The quarterly MDS documented a BIMS of 12, indicating moderate cognitive impairment, and no current self-administration of medication evaluation was documented. Although Resident #43 had an order for Combivent Respimat inhaler one puff every six hours as needed, the inhaler was observed on the bedside table, and the LPN verified it was there and stated she did not know if it was supposed to be at bedside. Resident #21 had diagnoses including UTI, adult failure to thrive, hyperlipidemia, hematuria, severe protein calorie malnutrition, neoplasm of the left kidney, COPD, pleural effusion, acute kidney failure, fracture of the upper end of the right humerus, hypertension, and cerebral infarction. The resident's MDS showed a moderate cognitive deficit, and the physician order included Fluticasone Propionate spray two sprays in each nares daily. No self-administration assessment was documented, yet the medication bottle was observed on the bedside table. An LPN verified the medication was stored improperly at bedside and should have been locked in the medication administration cart, and also verified there was no physician order or assessment for self-administration.
Vegetarian Diet Menu Not Followed
Penalty
Summary
The facility failed to prepare a vegetarian menu in advance and follow the menu for a resident with a physician order for a regular vegetarian diet. On 01/13/26 at 12:00 P.M., the resident received green peas, baked sweet potatoes, and a salad, but did not receive the baked ham listed on the menu. On 01/14/26 at 11:50 A.M., the resident received green beans and mashed potatoes from the kitchen, but did not receive the chicken or noodles listed on the menu. The resident had an admission date of 01/03/26, a history of dementia and right femur fracture, and a BIMS dated 01/07/26 showed severely impaired cognition. Interviews confirmed the resident was not receiving an entree as expected. The Area Director of Food Services verified the resident did not receive the entree and stated vegetarian options and always available meat-free menu items should have been provided. The resident's POA stated the resident followed a vegetarian diet and expected full meals. Culinary Support stated there was no vegetarian menu, though plant-based meats were available, and acknowledged the resident had dementia and might not be able to clearly express what she wanted. The DCS stated vegetarians were usually treated as a preference rather than a menu, but verified the resident should have received at least the noodles on 01/14/26 and should receive an entree; he also stated the kitchen had vegetarian options such as cottage cheese or egg salad.
Failure to Provide Ordered Diet Texture and Liquids
Penalty
Summary
The facility failed to provide the appropriate diet texture and liquid consistency as ordered for two residents. Resident #67 had diagnoses including femur fracture, COPD, heart failure, anxiety disorder, Parkinson’s disease, and convulsions. Her after-visit summary identified her as at moderate risk for aspiration and recommended IDDSI level 6 soft and bite-sized foods with IDDSI level 3 moderately thick liquids. However, her physician order specified a mechanical soft diet with honey or moderately thick liquids and 1:1 supervision during eating. During observation, Resident #67 was eating in her room with two pieces of toast and two whole sausage patties on her tray, and she also had cups of regular coffee and water that appeared thin. Her tray ticket showed a regular diet with no indication of thickened liquids. RN #392 confirmed the resident had not received the appropriate diet or liquids and stated it did not appear the kitchen had been updated with the resident’s current diet. Resident #65 had diagnoses including multiple orthopedic injuries, Parkinson’s disease, tremors, dysphagia, and depression. His nutrition assessment documented dysphagia with PEG tube placement after a failed MBS, and later his diet was changed to mechanical soft with thin liquids, 1:1 assist, and no bread. During lunch observation, he was served ground meat, sweet potato, green beans, and a dinner roll while eating with staff present. The Rehab Director confirmed the resident was on a mechanical soft diet but was unaware of the no-bread order, and the Administrator stated the dietary department used Meal Tracker and that if an update button was not clicked, the system could print the previous diet order on meal tickets, which led to residents not receiving the updated diet in MatrixCare.
Infection Control Lapses During Catheter and Wound Care
Penalty
Summary
The facility failed to maintain appropriate infection control practices for two residents. One resident was admitted with an indwelling urinary catheter related to urinary retention, and the care plan directed staff to maintain a closed system, keep the urinary bag below the bladder, and provide catheter care. During observation, the resident’s catheter collection bag was found laying on the floor of the room, and a CNA confirmed the condition of the bag. A second resident was admitted with a stage II pressure ulcer to the coccyx and a stage III pressure ulcer to the left heel, along with other skin issues and a Braden Scale score of 15 indicating risk for skin breakdown. The care plan included wound care and enhanced barrier precautions for high-contact care activities because the resident had chronic wounds. During wound treatment, an LPN removed the soiled dressing, cleansed the wound, and applied skin prep, but changed gloves without washing or sanitizing hands. The LPN also did not don the PPE required by the physician order for enhanced barrier precautions during the wound treatment. The facility policy for dressing changes required handwashing between glove changes and use of standard measures to minimize contamination, and the EBP policy stated that residents with chronic wounds and indwelling medical devices were to have enhanced barrier precautions during high-contact care activities.
Call Light Not Kept Within Reach for Resident in Recliner
Penalty
Summary
The facility failed to ensure Resident #49’s call light was kept within reach. During multiple observations on 01/12/26, 01/13/26, 01/14/26, and 01/15/26, the resident was seen sitting in her recliner with no call light available to her, while the call light was observed near her bed across the room. During interview on 01/15/26, a Certified Resident Care Associate confirmed the resident could use a call light, spent most of her time in the recliner, and had no way to call for staff because the regular wall call light did not reach the recliner and the resident did not have an extended cord or pendant. Resident #49 was admitted on 12/16/25 with diagnoses including unspecified mood disorder, pulmonary fibrosis, hypothyroidism, depression, anxiety, dementia, and hypertension. Her MDS assessment showed severely impaired cognition. Her care plan identified her as at risk for falls and included keeping the call light within reach. Additional documentation showed she was noncompliant with physician orders or the plan of care by refusing to sleep in bed and instead using her recliner, and progress notes repeatedly documented that she remained in the recliner for extended periods, including overnight and for the entirety of a nurse’s shift.
Failure to Timely Address and Document Resident Grievance Regarding Personal Property
Penalty
Summary
The facility failed to document and address a grievance made by a resident's representative in a timely manner. A resident, who was cognitively intact and had multiple complex medical diagnoses, was discharged to the hospital for ongoing medical issues. During his stay, the resident's family reported a missing lamp, which was later found in the facility's maintenance office. The lamp had been removed from the resident's room by the Plant Operations Director after it was discovered that it was plugged into an extension cord. The Plant Operations Director informed the resident about the removal, but there was no documented response from the resident. The family left a note on the resident's door requesting the return of the lamp, and the Administrator acknowledged being aware of this request. However, the Administrator did not return the lamp to the family and was unable to provide documentation of any grievance investigation, resident concern form, or resolution to the grievance. The facility's policy required concerns to be entered electronically and resolved within 24-48 hours, but there was no evidence that this process was followed in this case.
Failure to Timely Identify and Respond to Acute Change in Condition Resulting in Harm
Penalty
Summary
A deficiency occurred when staff failed to timely and adequately identify and respond to an acute change in a resident's medical condition, resulting in a delay in medical intervention and hospital care. The resident, who had a history of acute respiratory failure, congestive heart failure, high blood pressure, cardiomegaly, atrial fibrillation, and a previous hemorrhagic stroke, was admitted for short-term rehabilitation with the goal of returning home. On the night in question, the resident experienced an unwitnessed fall, reported not feeling well, and had multiple episodes of vomiting. Despite these symptoms and abnormal vital signs, including persistent hypotension, the staff did not initiate ordered intravenous (IV) fluids until approximately eight hours after the order was given by the Certified Nurse Practitioner (CNP). Throughout the day, the resident continued to exhibit concerning symptoms, such as refusing meals, ongoing vomiting, and low blood pressure readings. The CNP assessed the resident in the morning, ordered a chest x-ray, IV fluids, and a urinalysis, and noted abnormal laboratory results, including elevated white blood cell count and blood urea nitrogen. However, the IV fluids were not started until late in the afternoon, after a second episode of vomiting, and the urinalysis was not obtained. Staff interviews revealed confusion about the urgency of the IV fluid order, with some believing it was not a STAT order and therefore could be delayed. Later that day, the resident was found unresponsive and required cardiopulmonary resuscitation (CPR). Emergency Medical Services were called, and the resident was transported to the hospital, where CPR was continued, but the resident was ultimately pronounced deceased. The facility's policy required timely assessment and intervention for changes in condition, but the delay in initiating medical orders and failure to recognize the severity of the resident's symptoms contributed to actual harm.
Failure to Implement Fall Prevention Interventions for At-Risk Resident
Penalty
Summary
A deficiency was identified when a resident at risk for falls did not have appropriate fall prevention interventions in place as outlined in their care plan. The resident, who had a history of acute respiratory failure, congestive heart failure, cardiomegaly, atrial fibrillation, and a previous hemorrhagic stroke, was assessed as being at risk for falls due to poor mobility, a history of stroke, and general weakness. The Minimum Data Set assessment indicated the resident required staff assistance for transfers, ambulation, and personal hygiene, and had impaired cognition. Despite these risk factors, the resident was found on the floor after attempting to self-transfer from a recliner while wearing regular socks instead of the required non-skid footwear or shoes. Staff interview confirmed that the resident was not wearing non-skid socks or shoes at the time of the fall, contrary to the interventions specified in the resident's fall care plan. The facility's fall management policy requires maintaining a hazard-free environment and implementing preventative measures for residents at risk of falling. The failure to ensure the resident was provided with non-skid footwear as an intervention contributed to the fall incident.
Failure to Conduct Annual Performance Reviews for STNAs
Penalty
Summary
The facility failed to ensure that State tested Nursing Assistants (STNAs) received annual performance reviews, which had the potential to affect all residents residing in the facility. The facility census was 46 residents. Specifically, the employee file of an STNA hired on 05/30/23 contained a 90-day evaluation dated 11/10/23, but did not include an annual performance appraisal as of 10/17/24. During an interview, Business Office Staff confirmed the absence of an annual evaluation in the employee file and stated that they were not required to conduct evaluations after the 90-day evaluation. The administrator also confirmed the lack of an annual evaluation in the employee file.
Failure to Complete Required In-Service Training for STNA
Penalty
Summary
The facility failed to ensure that State tested Nurse Aides (STNAs) completed the minimum required 12 hours of in-service training annually. This deficiency was identified during a review of STNA #139's personnel record, which showed a hire date of 05/30/23 and completion of only six hours of training during orientation. Despite being assigned 12 hours of in-service or online training, STNA #139 did not complete the required training. Interviews with Business office staff member #136 and the administrator confirmed that STNA #139 did not fulfill the training requirements, which had the potential to affect all residents in the facility, with a census of 46.
Failure to Date Multi-Use Vials of Tuberculin PPD
Penalty
Summary
The facility failed to ensure that multi-use vials of tuberculin purified protein derivative (PPD) were dated when opened, as observed in the 200 hallway medication room. During an observation, three open and unlabeled vials of PPD were found, which were confirmed by the Director of Nursing (DON) to be undated. The facility had received the PPD solution on 09/26/24, and although the medication was not past its use-by date, the opened vials should have been labeled with the date they were opened. The facility's guidelines require that any medication in a multi-vial dose be used within 30 days of opening, with staff required to date and initial the vial upon opening. This oversight had the potential to affect 30 new admissions since 09/26/24, with a facility census of 46 residents.
Failure to Monitor and Administer Blood Pressure Medication
Penalty
Summary
The facility failed to properly monitor and administer blood pressure medication for two residents, leading to deficiencies in care. Resident #5, who had multiple medical conditions including hypertensive heart disease and chronic kidney disease, was prescribed hydralazine 25 mg as needed if her systolic blood pressure exceeded 140. However, her blood pressure was not consistently monitored daily as required, with checks only occurring on select dates. This lapse occurred after her skilled nursing services were discontinued, and the Director of Health Services confirmed that the necessary daily blood pressure checks were not conducted. Resident #27, who had significant cognitive impairment and multiple diagnoses including hypertensive chronic kidney disease, was prescribed hydralazine with specific parameters to hold the medication if her systolic blood pressure was below 100 or her pulse was below 60. Despite these parameters, there were multiple instances where her blood pressure fell below the safe levels, yet the medication was not held, nor was the physician notified. The Director of Health Services and a Registered Nurse confirmed that the standard practice was to hold the medication and notify the physician under such circumstances, which was not followed in this case.
Failure to Implement Fall Prevention Measures for a Resident
Penalty
Summary
The facility failed to implement care planned interventions for falls for a resident, identified as Resident #20, who was at risk for falls due to several medical conditions including hydrocephalus, disorientation, altered mental status, hemiplegia, type two diabetes, depression, and anxiety. The resident was severely cognitively impaired and required assistance with ambulation, as noted in the most recent Minimum Data Set (MDS) 3.0 assessment. The care plan, dated 06/16/23, identified the resident's risk for falls and included an intervention for a bed mat on the floor, dated 07/26/23, to mitigate this risk. During observations on 10/15/24, it was noted that the fall mat was not present at the bedside or anywhere in the resident's room, despite being a specified intervention in the care plan. Interviews with a Licensed Practical Nurse and a Certified Resident Care Associate confirmed the absence of the fall mat, acknowledging the resident's risk for falls. The Director of Nursing also confirmed the care planned intervention for a mat at the bedside. The facility's falls management program guidelines emphasized the importance of implementing all care plan interventions to maintain a hazard-free environment and mitigate fall risks.
Failure to Timely Review and Act on Pharmacy Recommendations
Penalty
Summary
The facility failed to provide evidence that pharmacy recommendations were reviewed in a timely manner for three residents. For Resident #5, pharmacy recommendations were made on multiple occasions, but there was no documentation to indicate when the physician addressed these recommendations. Similarly, for Resident #27, a pharmacy recommendation was made, but the physician did not date their response, and there was no supporting documentation to confirm when the recommendation was addressed. The Director of Health Services confirmed that the physician had not indicated the date of their response to the pharmacy recommendations. For Resident #7, several pharmacy recommendations were made over a period of months, but the physician's responses were not dated, making it unclear if they were completed in a timely manner. Additionally, a specific recommendation to discontinue Tramadol was agreed upon by the physician, but the medication was still in place at the time of the survey. The Director of Health Services verified that the physician had not dated their response and that the Tramadol order remained active despite the recommendation to discontinue it.
Deficiencies in Medication Management Due to Lack of Parameters
Penalty
Summary
The facility failed to provide proper parameters for the administration of medications for several residents, leading to deficiencies in medication management. Resident #5, who was cognitively intact, had an order for hydralazine to be administered as needed based on blood pressure readings. However, there was no order for daily blood pressure monitoring after skilled nursing services were discontinued, which was confirmed by the Director of Health Services (DHS) as an oversight. Resident #27, with significant cognitive impairment, had orders for hydralazine without parameters for blood pressure monitoring. The lack of parameters resulted in multiple instances where blood pressure was not taken before or after medication administration. Both the DHS and a Registered Nurse confirmed that parameters should have been set and that the physician should have been contacted if they were missing. Resident #137, who was cognitively intact, had orders for various pain medications without clear parameters for administration based on pain levels. This led to inconsistent administration of pain medications, with some medications not being given despite documented pain. Similarly, Resident #7 had orders for pain medications without parameters, resulting in the administration of medications without clear guidelines. The DHS confirmed the absence of parameters for 'as needed' pain medications for both residents.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate of five percent or less, resulting in a rate of 5.77 percent. This deficiency was identified during a review of medication administration for a resident diagnosed with hydrocephalus, disorientation, altered mental status, hemiplegia, type two diabetes, depression, and anxiety. The resident was severely cognitively impaired and required specific dietary and medication administration interventions. The facility's failure involved two medication errors out of 35 opportunities, affecting one resident. The errors occurred when an LPN administered a duloxetine delayed-release capsule by opening it and mixing the contents with applesauce, contrary to the prescribed method. Additionally, the LPN crushed a prednisone tablet, which was listed on the facility's Do Not Crush list due to its time-release formulation. The Director of Nursing confirmed that the duloxetine capsule should not have been opened and that prednisone should not have been crushed, highlighting the facility's failure to adhere to proper medication administration protocols.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 952 citations issued within 25 miles in the last 12 months — including the 10 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pickerington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pickerington Care And Rehabilitation | 2.3 mi | ★★★★★ | 28 | 0 |
| Robert A Barnes Center | 2.6 mi | ★★★★★ | 0 | 0 |
| Embassy Of Winchester | 4.3 mi | ★★★★★ | 5 | 0 |
| Altercare Of Canal Winchester Post-acute Rc | 4.8 mi | ★★★★★ | 36 | 1 |
| Canal Winchester Care Center | 4.8 mi | ★★★★★ | 17 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.