Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Walnut Hills Nursing Home during CMS and state inspections, most recent first.
Two residents were affected by the misappropriation of their narcotic medications by an LPN. One resident, unable to verify receipt due to their condition, had discrepancies in their medication records, while another resident with intact cognition reported not receiving their as-needed medication at night. The facility's investigation confirmed the LPN did not administer the medications as recorded, leading to the misappropriation.
The facility inaccurately reported staff hours in the PBJ report, affecting all residents. Despite having licensed nurses on duty, the report showed gaps in coverage due to issues with obtaining agency staff invoices, as confirmed by the DON.
The facility failed to ensure proper hand hygiene during meal service, affecting two residents and potentially impacting others. CNAs were observed serving lunch trays without washing or sanitizing their hands between handling trays and assisting residents, contrary to the facility's Infection Prevention and Control policy.
An LPN failed to perform hand hygiene during medication administration for two residents, despite facility policy requiring it between resident contacts. The LPN administered medications, handled cups, and documented without washing or sanitizing hands, affecting residents with specific medical orders for pain and diuretic medications.
A facility failed to follow physician-ordered oxygen settings for a resident with respiratory needs. The resident, with a history of respiratory disorder, dementia, and breast cancer, had an order for continuous oxygen at 1 to 2 LPM. However, the oxygen concentrator was set at 0.5 LPM, as confirmed by the DON. This was against the facility's policy requiring adherence to physician orders.
A facility failed to update its antibiotic stewardship policy, leading to inappropriate antibiotic use for a resident. The resident, with heart failure and chronic kidney disease, was given Augmentin despite a urine culture showing mixed microbiota and no infection criteria met. The facility's policy still referenced outdated criteria, causing a discrepancy in practice.
The facility failed to prevent and manage pressure ulcers for three residents, leading to the development and worsening of ulcers. A resident at high risk developed multiple facility-acquired pressure ulcers due to missed treatments and lack of necessary equipment. Another resident's wound declined due to inconsistent care and delayed implementation of physician orders. A third resident developed an unstageable pressure ulcer, with treatments and interventions not consistently provided. The facility did not adhere to its pressure injury prevention policy.
Two residents reported that their mail was opened by staff without permission, violating their rights to confidentiality. One resident's package was returned to sender without notification. Staff admitted to opening mail due to concerns about package contents but failed to obtain resident consent.
A facility failed to provide the correct ostomy supplies for a resident with a colostomy, as ordered by the physician. The resident was using an incorrect size ostomy bag due to the facility's lack of the ordered supplies. The resident's care plan also lacked details regarding the colostomy care and supplies, leading to non-compliance with physician orders.
A facility failed to obtain daily weights for a resident with severe malnutrition as ordered by the physician. Despite the resident's significant weight loss and the dietitian's expectation for daily monitoring, weights were only recorded on a few occasions over a month. This non-compliance was identified during a complaint investigation.
A resident with serious medical conditions did not receive timely intravenous antibiotics due to the facility's pharmacy services failing to deliver medications and supplies as needed. The resident missed several doses of Ceftriaxone and Ampicillin, and the facility lacked a pharmacy policy, contributing to the deficiency.
The facility failed to maintain accurate medical records for three residents, leading to medication administration discrepancies and inadequate care. A resident received conflicting Torsemide dosages, another had undocumented Ceftriaxone administration, and a third lacked a prescribed specialty mattress, resulting in pressure ulcers. The DON confirmed these inaccuracies.
The facility failed to maintain infection control practices for two residents. An LPN did not change gloves during wound care for a resident with pressure ulcers, and an STNA did not change gloves during incontinence care for a resident with dementia. Both actions violated facility policies.
The facility failed to ensure that state survey results were readily accessible, affecting all 45 residents. Observations revealed that the most recent health inspection was completed on a past date, and complaint inspections were completed on various dates. However, the facility did not post the survey results for the complaint investigations completed on these dates. The facility's posting corkboard did not include the plan of correction for the most recent health inspection survey results, and no survey results were available for review after a certain date.
The facility did not post daily nurse staffing information in a visible area, affecting all 45 residents. Observations on multiple days showed the data was not readily accessible, with the Scheduling Coordinator unaware of the visibility requirement. On several occasions, the staffing data was outdated or not posted at all, as confirmed by staff interviews.
A medication assistant at the facility performed duties outside her scope of practice, including documenting pain levels, assessing residents, and notifying physicians, affecting four residents with various medical conditions. The Director of Nursing confirmed the medication assistant had been educated on her scope of practice, but the facility's job description did not support the tasks performed.
The facility failed to maintain a medication error rate of less than five percent, resulting in an 11.0% error rate. Two residents were affected: one received the wrong dosage of lactulose and expired eye drops, while the other was not instructed to rinse her mouth after using an asthma inhaler.
Misappropriation of Resident Medications by LPN
Penalty
Summary
The facility failed to protect residents from the misappropriation of their medications, specifically affecting two residents. One resident, who was unable to be interviewed and dependent on staff for activities of daily living, had discrepancies in the administration of their prescribed Oxycodone. The medication administration records did not show that the as-needed Oxycodone was administered, and the resident, who typically slept through the night, was unable to verify receipt of the medication. Similarly, another resident with intact cognition and also dependent on staff for daily activities, reported not receiving the as-needed Oxycodone during the night, despite it being signed out by an LPN. This resident confirmed receiving their routine medication at scheduled times by a different LPN. The facility's investigation revealed that the LPN responsible for signing out the medications did not administer them as recorded, leading to the misappropriation of narcotic medications. The discrepancies were discovered when another LPN noticed inconsistencies in the narcotic sheets, prompting an investigation. The facility substantiated the self-reported incident and took steps to report the LPN to relevant authorities, including the Ohio Board of Nursing, Ohio Board of Pharmacy, and the local police department.
Inaccurate PBJ Staffing Report Due to Invoice Issues
Penalty
Summary
The facility failed to completely and accurately report staff hours worked for the Payroll Based Journal (PBJ) report, which had the potential to affect all 41 residents residing in the facility. Specifically, the PBJ report indicated that the facility did not have licensed nursing coverage 24 hours per day on several dates in June 2024. However, a review of the staffing schedules for those dates revealed that there was indeed a licensed nurse present in the facility. An interview with the Director of Nursing (DON) confirmed that the corporate office experienced difficulties obtaining invoices for agency staff, which resulted in the inaccurate submission of staffing data for the specified dates.
Failure to Perform Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to adhere to proper hand hygiene protocols during meal service, affecting two residents directly and potentially impacting all 13 residents on the skilled unit. On the specified date, a Certified Nursing Assistant (CNA) was observed serving lunch trays to residents in the dining room without washing or sanitizing his hands between handling the trays and assisting residents with their meals. This included actions such as removing lids and cutting up meat for the residents. The CNA acknowledged during an interview that he did not perform hand hygiene during the meal service, which was contrary to the facility's Infection Prevention and Control policy. Another CNA was observed retrieving and serving lunch trays to residents in their rooms without performing hand hygiene between serving different residents. This CNA also confirmed during an interview that she did not wash or sanitize her hands between serving the trays to two different residents. The facility's policy, dated March 2020, clearly states that all staff must wash their hands between resident contacts and after handling contaminated objects, which was not followed in these instances.
Failure in Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to perform proper hand hygiene during medication administration, affecting two residents. An LPN was observed administering medications to residents without washing or sanitizing their hands before, during, or after the process. Specifically, the LPN sanitized their hands before preparing a narcotic medication for one resident and then proceeded to administer the medication without further hand hygiene. After administering the medication, the LPN handled the medication and water cups, disposed of them, and documented the administration without washing or sanitizing their hands. The deficiency was confirmed through an interview with the LPN, who acknowledged the failure to perform hand hygiene as required. The facility's policy on infection prevention and control mandates that staff wash their hands between resident contacts and after handling contaminated objects, among other situations. The residents involved had specific medical orders for pain and diuretic medications, which were administered by the LPN without adherence to the hand hygiene protocol.
Failure to Follow Physician-Ordered Oxygen Settings
Penalty
Summary
The facility failed to adhere to physician-ordered oxygen settings for a resident requiring respiratory care. Resident #15, who was admitted with diagnoses including a respiratory disorder, dementia, and breast cancer, had a physician's order for continuous oxygen administration at 1 to 2 liters per minute (LPM) via nasal cannula to maintain oxygen saturation levels above 90%. However, during an observation, the oxygen concentrator in the resident's room was set at 0.5 LPM, contrary to the prescribed order. The discrepancy was confirmed during an interview with the Director of Nursing (DON), who acknowledged that the oxygen concentrator setting did not align with the physician's order. The facility's policy on oxygen administration, which mandates adherence to physician orders except in emergencies, was not followed in this instance. This oversight affected the resident's prescribed respiratory care, as documented in the Medication Administration Record, which showed oxygen saturation levels ranging from 90% to 97% during the period in question.
Failure to Update Antibiotic Stewardship Policy
Penalty
Summary
The facility failed to update and implement their antibiotic stewardship program policy, which led to inappropriate antibiotic use for a resident. Resident #30, who was admitted with diagnoses including heart failure and chronic kidney disease, reported bladder discomfort and an inability to void. A urine culture indicated mixed microbiota, suggesting possible contamination, and no antibiotic sensitivity was identified. Despite this, the resident was started on Augmentin for seven days based on a progress note dated 08/16/24, even though the McGeer Criteria for Infection Surveillance Checklist indicated that the criteria for a urinary tract infection were not met. The Director of Nursing confirmed that the facility used the McGeer Criteria instead of the Loeb Criteria to determine the necessity of antibiotics, yet the facility's Antibiotic Stewardship Policy had not been updated to reflect this change. The policy still referenced the Loeb Minimum Criteria, leading to a discrepancy between the policy and practice. This oversight resulted in the administration of antibiotics without appropriate culture results to identify the infection's susceptibility, highlighting a failure in the facility's antibiotic stewardship program.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate care and services to prevent the development and decline of pressure ulcers for three residents. Resident #87, who was at high risk for pressure ulcers, developed multiple facility-acquired pressure ulcers. The facility did not complete the required Braden Risk assessments and failed to provide the ordered treatments, including the use of a low air loss mattress. Observations revealed that the resident was not provided with the necessary equipment and treatments, leading to the worsening of the pressure ulcers. Resident #37 was admitted with multiple diagnoses and was at risk for pressure ulcers. The facility did not complete the required risk assessments after the initial one and failed to provide consistent wound care as ordered. The resident's wound showed a decline, with an increase in necrotic tissue, due to missed treatments and delays in implementing new physician orders. The care plan for the resident's wound was not followed, contributing to the deterioration of the wound. Resident #91, who was at risk for pressure ulcers, developed an unstageable pressure ulcer on the left heel. The facility did not complete additional risk assessments after the initial one and failed to provide the necessary treatments and interventions consistently. There was no evidence of nutritional support ordered for the resident's pressure ulcer, and the facility's documentation indicated that treatments were not completed as required. The facility's policy on pressure injury prevention and management was not adhered to, resulting in the development and worsening of pressure ulcers for the residents.
Failure to Ensure Confidentiality of Resident Mail
Penalty
Summary
The facility failed to ensure the confidentiality of residents' mail, affecting two residents out of a sample of five. Resident #79 reported that her mail, including a retail store package and a wireless service provider bill, was opened by staff without her permission. Despite having severe arthritis, Resident #79 stated she could open her own mail or would have preferred to be asked for assistance. Charge Nurse #108 admitted to opening the mail and package, claiming she was instructed to do so because the package sounded like it contained a bottle of pills. However, she did not disclose who gave the instruction and acknowledged that she should have obtained permission from the resident. Resident #91 also reported receiving opened mail without giving permission. Additionally, she was waiting for a package ordered by her daughter, which she had not received. The Life Enrichment Director (LED) #126 explained that the package was returned to the sender because it was addressed to the daughter, not the resident, and the facility had not informed Resident #91 or her daughter about this. The LED confirmed that residents have the right to receive unopened mail and that mail should only be opened with permission. The Business Office Manager stated she does not open resident mail or packages, indicating a lack of consistent policy enforcement across the facility.
Failure to Provide Ordered Ostomy Supplies
Penalty
Summary
The facility failed to ensure that the appropriate ostomy supplies were available for a resident with a colostomy, leading to non-compliance with physician orders. Resident #9, who was admitted with diagnoses including a hip fracture, weakness, atrial fibrillation, constipation, and a colostomy, was ordered to use specific ostomy supplies: [NAME] Wafer #11402 and [NAME] Bag #18182, to be changed every three days and as needed. However, during an observation, it was found that the resident was using an ostomy bag #18373, which was not the size ordered by the physician. The resident confirmed that these were the only supplies available for use. Further investigation revealed that the facility did not have the physician-ordered size ostomy bag available. The charge nurse confirmed that the resident had been discharged and readmitted on the same day without bringing back her ostomy supplies, leading to the use of the incorrect size since readmission. Additionally, the resident's care plan did not include any mention of the colostomy or interventions related to the supplies or care frequency, indicating a lack of comprehensive care planning for the resident's condition.
Failure to Obtain Daily Weights as Ordered
Penalty
Summary
The facility failed to obtain daily weights for a resident as ordered by the physician, which is a deficiency in following medical orders. The resident, who was admitted with multiple serious health conditions including severe protein calorie malnutrition, was supposed to have their weight monitored daily due to a significant weight loss prior to admission. However, the facility did not complete daily weight checks as required, with weights only recorded on a few specific dates over a month-long period. The resident's medical record indicated that daily weights were ordered, and this was confirmed by the dietitian, who expected the orders to be followed and documented in the electronic record. Despite this, the facility's records showed that daily weights were not consistently obtained, which represents non-compliance with the physician's orders. This deficiency was identified during an investigation under a specific complaint number.
Failure to Administer IV Medications Timely
Penalty
Summary
The facility failed to ensure timely administration of intravenous medications for a resident, leading to missed doses of critical antibiotics. Resident #45, who was admitted with diagnoses including cerebral infarction, bacteremia, and sepsis, had physician orders for Ceftriaxone and Ampicillin to be administered intravenously. However, the Medication Administration Record indicated that several doses of these antibiotics were not administered as ordered on multiple occasions in June 2024. The certified nurse practitioner was notified of the missed doses, and the order was extended to compensate for the missed doses. The deficiency was attributed to the facility's pharmacy services, which failed to deliver the necessary medications and supplies in a timely manner. The Director of Nursing reported difficulties in contacting the pharmacy over a weekend, resulting in missed doses due to the lack of medication or IV tubing. Pharmacy records showed discrepancies in delivery and dispensing, with some supplies running out prematurely. Additionally, the facility lacked a policy for pharmacy services, as confirmed by the Administrator. This deficiency was investigated under Complaint Number OH00154465.
Inaccurate Medical Records and Medication Administration
Penalty
Summary
The facility failed to maintain accurate medical records for three residents, leading to discrepancies in medication administration and care. For Resident #99, there was a conflict between the hospital discharge instructions and the electronic Physician's Orders regarding the dosage of Torsemide, a diuretic. The discharge instructions prescribed 40 mg once a day, while the electronic orders indicated two tablets of 20 mg daily, leading to confusion over whether the resident was receiving 20 mg or 40 mg. This inconsistency was confirmed by the Director of Nursing during an interview. Resident #45's medical records showed a failure to document the administration of Ceftriaxone, an antibiotic, on a specific date, despite interdisciplinary notes indicating it was administered. The Director of Nursing verified this omission. Additionally, Resident #87's records inaccurately reflected the use of a specialty pressure-relieving mattress. Although a low-air loss mattress was recommended and ordered, the resident was observed on a standard mattress, which contributed to the development of pressure ulcers. The Director of Nursing was unaware of the discrepancy until it was pointed out during an observation.
Infection Control Deficiencies in Wound and Incontinence Care
Penalty
Summary
The facility failed to maintain adequate infection control practices, affecting two residents. Resident #87, who was admitted with diagnoses including post-polio syndrome and hip fracture, developed two facility-acquired pressure ulcers. During an observation of wound care, an LPN did not change gloves after cleansing the wound or during the dressing change, contrary to the facility's policy. The LPN acknowledged the oversight, attributing it to the resident having just had a bath. Resident #25, admitted with dementia and other conditions, was observed receiving incontinence care. The STNA assisting the resident did not change gloves during the process, despite handling soiled materials. This was in violation of the facility's perineal care policy, which requires changing gloves if they become soiled. The STNA confirmed the failure to change gloves during an interview.
Failure to Post Recent Survey Results
Penalty
Summary
The facility failed to ensure that state survey results were readily accessible for review, including the most recent survey of the facility. This deficiency had the potential to affect all 45 residents residing in the facility. Observations and reviews revealed that the most recent health inspection was completed on 09/23/22, and complaint inspections were completed on various dates, including 03/13/23, 05/04/23, 02/06/24, and 04/04/24. However, the facility did not post the survey results for the complaint investigations completed on 03/13/23, 02/06/24, or 04/04/24. During an observation on 06/25/24, it was noted that the facility's posting corkboard did not include the facility's plan of correction for the most recent posted health inspection survey results dated 09/23/22. Additionally, other survey results posted were dated from 12/05/19 through 05/04/23, with no other survey results available for review after the survey completed on 05/04/23. Further observations on 06/26/24 revealed that the most recent survey results available in the receptionist area were dated 09/23/22, and the Business Office Manager confirmed the lack of posted survey results for the more recent complaint investigations.
Failure to Post Nurse Staffing Information Visibly
Penalty
Summary
The facility failed to post daily nurse staffing information in a location that was readily visible, potentially affecting all 45 residents. On multiple occasions, observations revealed that the nurse staffing data was not posted in a visible area. On June 25, 2024, and June 26, 2024, the data was not visible, and it was found on a clipboard wedged between bookends and a binder, not easily accessible to residents, visitors, or staff. The Scheduling Coordinator confirmed the data was not visible and was unaware of the requirement for it to be visible at all times. On June 27, 2024, the staffing data for the previous day was still posted, and the current day's data had not been updated. Similarly, on July 2, 2024, the data posted was from the previous day, and the current day's data was not available. These findings were part of an investigation under Complaint Number OH00154465.
Medication Assistant Exceeded Scope of Practice
Penalty
Summary
The facility failed to ensure that a medication assistant did not perform duties outside her scope of practice, affecting four residents. Resident #25, who had multiple diagnoses including low back pain, diabetes, and hypertension, had her pain levels documented by the medication assistant (MA-C #101) on multiple occasions in February and March 2024. Additionally, MA-C #101 documented details about Resident #25's fall and injury without follow-up documentation from a licensed nurse. The medication assistant also cleaned and bandaged the resident's knee and notified the Nurse Practitioner (NP) of the fall, actions that should have been performed by a licensed nurse. Resident #32, who had diagnoses including diabetes and bipolar disorder, also had her pain levels documented by MA-C #101 in February and March 2024. The medication assistant documented the resident's behaviors and medication refusals, actions that were outside her scope of practice. MA-C #101 stated she was told by the Director of Nursing that she could document these behaviors. Similarly, Resident #38, who had diagnoses including cerebral infarction and dementia, had her pain levels documented by MA-C #101 in February and March 2024. The medication assistant also documented a diet change for Resident #38 without an official order or verification from a licensed nurse. Resident #35, who had multiple diagnoses including malignant neoplasm of the colon and heart failure, had her pain levels documented by MA-C #101 in February and March 2024. The medication assistant revealed she had been completing resident assessments instead of a nurse to administer as-needed medications. The Director of Nursing confirmed that the medication assistant had been educated on her scope of practice but expressed that the role of medication assistants was limited if they could only administer medications. The facility's job description for a medication aide did not include the tasks performed by MA-C #101, indicating a clear violation of scope of practice regulations.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in an error rate of 11.0%. This deficiency affected two residents. For Resident #45, the medication assistant (MA-C) administered only 15 milliliters of lactulose syrup instead of the prescribed 30 milliliters and used expired Refresh tears eye drops. The MA-C verified these errors when stopped by the surveyor. Resident #45 had multiple diagnoses, including cerebral infarction, hemiplegia, dysphagia, and congestive heart failure, and had moderately impaired cognition according to the quarterly MDS assessment. For Resident #49, the MA-C failed to instruct the resident to rinse her mouth after administering Fluticasone propionate diskus, an asthma medication. Despite the resident asking if she needed to rinse her mouth, the MA-C incorrectly informed her that it was unnecessary. The manufacturer's instructions for the medication clearly state that rinsing the mouth is required to reduce the risk of oropharyngeal candidiasis. Resident #49 had intact cognition and multiple diagnoses, including dementia, asthma, and chronic respiratory failure.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Walnut Creek
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oak Pointe Nursing & Rehabilitation | 6.7 mi | ★★★★★ | 0 | 0 |
| Scenic Pointe Nursing And Rehab Ctr | 8.1 mi | ★★★★★ | 6 | 0 |
| Majora Lane Ctr For Rehab & Nsg Care Inc | 10.3 mi | ★★★★★ | 12 | 0 |
| Sycamore Run Nursing And Rehab Ctr | 10.8 mi | ★★★★★ | 4 | 0 |
| Hennis Care Centre Of Dover | 12.3 mi | ★★★★★ | 0 | 0 |
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