Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 Wellspring Health Center during CMS and state inspections, most recent first.
A resident with multiple comorbidities, bilateral upper and lower extremity impairments, and a documented high fall risk was care planned and documented as requiring two-person assistance for bed mobility and toilet hygiene. Despite this, a single CNA provided peri-care in bed and rolled the resident onto his side away from her, during which the resident’s hand lost strength and he fell from the bed to the floor. The resident sustained multiple fractures to the right humerus and elbow and the left femur and patella. The DON later confirmed that the resident’s care plan and Kardex had long specified two-person assistance for these tasks, while the resident reported that only about half the time were two staff present during incontinent care.
Food service staff failed to follow food safety and hygiene practices in the kitchen and serving areas. Clean pans, trays, and serving items were stacked while still wet instead of being fully air dried, several food items were left open or undated, and an opened box of hamburgers was exposed in the freezer. Staff were also observed with facial hair not covered by beard restraints, long hair not fully contained in hairnets, and improper handwashing technique, including washing for less than 20 seconds and touching the faucet with clean hands.
Visible Catheter Bag Without Privacy Cover: A resident with an indwelling urinary catheter and significant cognitive impairment was observed seated near the room doorway with the drainage bag containing urine visible from the hallway and no privacy cover in place. CNA and RN staff confirmed the bag was visible and not expected to be seen from the hallway, and the DON stated the bag should have been covered at all times per facility policy to maintain privacy and dignity.
Failure to Provide Routine Nail Care: A resident with moderate cognitive impairment and dependence for personal hygiene had fingernails that were about one half inch long with dirt under them. The care plan and facility policy directed staff to check, trim, and clean nails during ADL care, but CNAs and the DON observed that the nails were too long and dirty, and staff stated nail care was tied to shower days even though documentation did not clearly show when showers or nail care occurred.
A resident with a history of colon neoplasm, pain, constipation risk, and bowel incontinence went more than three days without a documented BM. The CNA was expected to chart BMs in the EMR and staff were expected to monitor alerts, but the record showed no documented use of the PRN bisacodyl suppository and an EMR alert indicated no BM for three days. Interviews showed the resident believed staff should have known about the constipation, while the DON stated the alert should have prompted follow-up and possible physician notification.
Delayed Refill of PRN Oxycodone: A resident with chronic pain, osteoarthritis, dorsalgia, and intact cognition went without PRN oxycodone for seven days because staff, the provider, and the pharmacy did not coordinate the refill effectively. Nursing notes, staff interviews, and fax records showed repeated attempts to obtain the narcotic, confusion about faxing and on-call coverage, and a delay in getting the prescription to the pharmacy. The resident reported the facility had run out of the medication and that Tylenol was offered instead.
A cognitively impaired resident with a history of wandering and high elopement risk was admitted for hospice respite and began exit-seeking soon after arrival. Despite these behaviors, no care plan was implemented for elopement risk, and the resident was left unsupervised in the memory care unit. The resident exited through a stairwell door with a malfunctioning alarm, which had been disabled by rodent damage, and fell down a flight of stairs, sustaining multiple fractures and injuries before being found and transported to the hospital.
A resident with an indwelling catheter and significant care needs received peri and catheter care from a CNA who used the same wash cloths for both the front and back areas, including after a bowel movement, and did not change gloves during the process. The CNA also touched various items in the resident's environment with soiled gloves, contrary to facility policy requiring hand hygiene and glove changes.
An LPN at the facility pre-poured medications for eight residents, contrary to the facility's policy that prohibits preparing medications in advance. The LPN, an agency nurse, was unsure if this practice was allowed at the facility, although she had done it at other facilities.
The facility failed to follow physician orders for weekly weights for three residents, leading to a deficiency. A resident with cognitive impairment and risk for weight loss had missing weight records due to a lapse in order entry after hospitalization. Another resident with diabetes and renal insufficiency also had missing weights, despite being at risk for weight loss. A third resident with heart failure was not weighed weekly, with some refusals undocumented. These issues were confirmed by the RD and part of a complaint investigation.
A resident with Alzheimer's did not receive the correct dosage of Folic Acid due to an error by an agency LPN, who administered an 880 mcg tablet instead of the prescribed 1 mg. The LPN, unfamiliar with the facility, noted the pharmacy had not sent the correct medication and proceeded without addressing the discrepancy, contrary to the facility's medication administration policy.
Failure to Follow Two-Person Assistance Requirements During Incontinent Care Resulting in Fall and Fractures
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate physical assistance and supervision during incontinent care for a resident who was dependent on staff for toileting, personal hygiene, and bed mobility. The resident had multiple diagnoses, including osteoarthritis, congestive heart failure, chronic kidney disease, dementia, cardiomyopathy, and polyneuropathy, and was assessed as cognitively intact but with impairments in both upper and lower extremities. His care plan and ADL documentation indicated he was totally dependent on two staff for bed mobility, including use of a draw sheet to move him in bed, and dependent on staff for toilet hygiene and personal hygiene. A fall risk assessment score of 12 identified him as at risk for falls. On the date of the incident, one CNA provided peri-care to the resident while he was in bed, despite the care plan and Kardex indicating he required two-person assistance for bed mobility and toilet hygiene. During this care, the CNA rolled the resident onto his left side, away from her, to clean him. While in this position, the resident’s hand lost strength and he fell from the bed to the floor. At the time of the fall, only one aide was assisting him, and the LPN on duty later confirmed she was not aware of his staffing care levels but acknowledged that only one aide had been providing care when the fall occurred. Following the fall, the resident reported significant pain in his right arm, and a hard lump was noted near his right elbow. Subsequent hospital imaging confirmed multiple fractures: a right distal humerus supracondylar traverse closed fracture, a right coronoid non-displaced fracture, a left distal femur supracondylar closed fracture, and a left patella fracture, with documentation stating these injuries occurred when he slipped off the bed while his brief was being changed. The DON confirmed that the resident’s records and care plan had long indicated the need for two-person assistance for bed mobility and toilet hygiene, and the resident reported that only about half the time were two staff present during incontinent care or cleaning in bed. The facility’s fall prevention policy required assessment and care planning for fall risk, but the resident’s established need for two-person assistance was not followed at the time of the incident, resulting in the fall and injuries.
Food Storage, Drying, and Hygiene Deficiencies in Dietary Services
Penalty
Summary
The facility failed to ensure meals were prepared and food was stored in accordance with professional food safety standards. During observations in the main kitchen and the SNF serving kitchen, clean steam table pans, soup buckets, insulated serving bases and domes, and trays were stacked while still wet, with significant moisture visible between the items. The facility policy required dishes and utensils to air dry before storage and not be towel dried, and staff interviews confirmed the expectation that items should be fully air dried before being put away and should not be stacked when wet. The facility also failed to store food items in a sanitary manner. Large bins of rice, flour, sugar, and panko were labeled but not dated. In the serving kitchen, an opened hot dog bun and an opened bagel were found without labels or dates, and the dietary manager discarded them during the observation. In the freezer, an opened box of beef hamburgers was observed unsealed and exposed on a shelf. Later observations found a half loaf of white bread and a half loaf of wheat bread not securely closed. Staff interviews confirmed that opened food items were expected to be labeled and dated, bread should be tightly sealed if not in use, and freezer items should be closed and sealed. The facility also did not follow its own personal hygiene expectations for food service staff. The dietary services manager and the executive chef were observed with facial hair in food preparation areas without beard coverings. Two dietary aides were observed with long braided hair that was not fully contained in their hairnets, and one of them also had facial hair without a beard guard. In addition, hand hygiene observations showed a dietary aide washing for about seven seconds and turning off the faucet with clean hands, and the dietary services manager turning off the faucet with wet hands and not washing for 20 seconds. The facility policy and posted handwashing guide required hair restraints, beard restraints, and handwashing for at least 20 seconds with paper towels used to turn off the water.
Visible Catheter Bag Without Privacy Cover
Penalty
Summary
The facility failed to ensure care was provided in a dignified manner for one resident with an indwelling urinary catheter. Resident #43 was admitted with diagnoses including acute kidney failure and neuromuscular dysfunction of the bladder, and the admission MDS indicated severe impairment in cognitive skills for daily decision-making, short- and long-term memory problems, dependence with toileting hygiene, and an indwelling urinary catheter. The care plan identified the resident’s catheter as related to a neurogenic bladder and directed staff to provide catheter care per facility policy. An observation showed the resident seated in a wheelchair near the doorway to the room with the catheter drainage bag attached to the wheelchair, containing urine, visible from the hallway, and without a privacy cover. During interviews, CNA #13 and RN #14 both stated the bag was visible from the hallway and was not expected to be visible, and CNA #13 stated staff were expected to place privacy covers on visible catheter drainage bags. The family member stated the resident had not had a privacy cover on the catheter drainage bag since admission. The DON stated the catheter drainage bag should have been in a privacy cover at all times, that the resident returned from the hospital without one, and that staff should have replaced it upon admission. The facility policy stated catheter bags should not be visible in public areas and that a catheter bag cover should be used to maintain privacy and dignity.
Failure to Provide Routine Nail Care
Penalty
Summary
The facility failed to ensure fingernails were clean and trimmed for one resident who required substantial to maximal assistance with personal hygiene. Resident #26 was admitted with diagnoses including contracture of the right hand, adjustment disorder, and mild cognitive impairment, and a quarterly MDS showed a BIMS score of 9, indicating moderate cognitive impairment. The resident’s care plan directed staff to check nail length, trim nails, and clean nails on bath days and as necessary, and the facility policy stated nail cleaning and inspection were to be provided during ADL care on an ongoing basis. Observations showed the resident’s fingernails were about one half inch long on 12/01/2025 and again on 12/03/2025, when brown substance was seen under the nails. The resident stated they would let someone cut and clean the nails and that the nails did need to be trimmed. During the same observation, a CNA stated nail care was provided when showers were provided and that the resident was showered twice a week, then confirmed the nails needed to be trimmed and had dirt under them. The DON also observed the nails and stated they were too long and dirty, and said CNAs and nurses provided nail care when residents were showered or whenever needed. The DON later stated the facility did not have shower sheets and could not determine from the EMR when showers were provided because personal care was documented under one category. The ADM stated CNAs were responsible for monitoring fingernails when showers were provided, and the DON identified several CNAs who had provided showers to the resident, while a lead CNA stated she did not provide nail care during the resident’s shower and did not remember whether the nails were long or dirty.
Failure to Address Resident’s Lack of Bowel Movement
Penalty
Summary
The facility failed to provide proper bowel management for one resident who had diagnoses including benign neoplasm of the colon and unspecified pain, was assessed as cognitively intact, required substantial to maximal assistance with toileting hygiene, and was always incontinent of bowel. The resident’s care plan identified constipation related to decreased mobility and opioid use, and the resident had standing orders for daily senna and as-needed bisacodyl suppository for constipation. The resident’s bowel documentation showed a continent bowel movement on 11/27/2025 and then no documented bowel movement until an incontinent bowel movement on 12/03/2025, a span of six days. The MARs showed the scheduled senna was administered as ordered, but there was no documented evidence that the as-needed bisacodyl suppository was given during the period without bowel movements. The resident stated they thought it had been about a week since their last bowel movement, did not feel they should have to tell staff, and believed constipation caused their stomach to feel bruised. Staff interviews and record review showed the CNA was responsible for documenting bowel movements in the EMR and would notify the nurse if a resident had not had a bowel movement in two to three days, while the nurse and leadership were expected to monitor the EMR alerts. When the EMR was reviewed, an alert was visible indicating the resident had not had a bowel movement in three days, and staff stated the alert had not been cleared. The DON stated the last documented bowel movement was 11/27/2025, that an alert should have appeared three days later, and that the physician should have been notified if the documentation was accurate; however, the resident’s lack of bowel movement for over three days was not addressed in the record.
Delayed Refill of PRN Oxycodone
Penalty
Summary
The facility failed to ensure effective coordination between staff, the provider, and the pharmacy for a refill of as-needed oxycodone for one resident. The resident was admitted in 2020 and had diagnoses including contracture of the right lower leg muscle, osteoarthritis, unspecified pain, and dorsalgia. The resident’s annual MDS showed a BIMS score of 15, indicating intact cognition, and the resident had an opioid medication on the MDS. The care plan identified chronic pain related to multiple conditions, with interventions to administer pain medication as ordered and before treatments or care as indicated. The resident had an active order for oxycodone HCL 5 mg by mouth every eight hours as needed for pain. The MAR showed oxycodone was administered on multiple days in November, then was not administered for seven consecutive days before being given again. Nursing notes showed a request for a new prescription was sent to the MD, a call was placed to the on-call medical doctor because a prescription was needed, and another fax request was sent when the prescription had still not been received. A facility fax transmission record later showed a prescription for 75 tablets of oxycodone HCL, and the pharmacy delivery manifest showed 30 tablets were delivered to the facility after the delay. Interviews showed the resident stated the facility had run out of the medication for about 10 days and that staff were told the resident needed oxycodone. The resident also stated Tylenol was offered and was effective for mild pain, but the resident was uncomfortable when the opioid was unavailable. Staff interviews showed confusion and breakdowns in the refill process: one LPN stated the pharmacy did not have a prescription and the on-call provider would not provide a narcotic prescription; another nurse stated the fax machine may not have been receiving the request; the ADON stated staff should have been checking Documo for incoming faxes and that the prescription was not sent to the pharmacy until several days after it was received back from the MD; the DON stated she was not aware the resident was out of oxycodone; and the MD stated the pharmacy should have contacted him for an emergency three-day supply and that he was never contacted.
Failure to Prevent Elopement and Injury Due to Inadequate Supervision and Malfunctioning Door Alarm
Penalty
Summary
A deficiency occurred when a cognitively impaired resident with a diagnosis of vascular dementia, atrial fibrillation, and heart failure, who was assessed as being at high risk for elopement, was admitted for a seven-day hospice respite. The resident began exhibiting wandering and exit-seeking behaviors shortly after admission. Despite these behaviors and the resident's high risk for elopement, there was no care plan implemented to address the resident's cognitive impairment or elopement risk. The resident was initially placed on an unsecured floor and later moved to a secured memory care unit (MCU) with a Wanderguard device applied. On the day of the incident, the resident was last seen in the common area near the nurse's station, eating a snack. Staff, including the DON and a CNA, left the area to provide care to another resident, leaving the resident unsupervised. Approximately 40 minutes later, staff realized the resident was missing. A search was conducted, and the resident was found at the bottom of a stairwell between the second and third floors, having fallen down 11 cement stairs. The resident suffered multiple injuries, including fractures to the left scapula, several ribs, abrasions, lacerations, and contusions. The resident did not recall the fall and was transported to the hospital for evaluation and treatment. Investigation revealed that the stairwell door alarm was not functioning due to wires that had been chewed through by rodents, resulting in the alarm not sounding when the door was opened. Maintenance records showed no documentation of prior issues with the door alarms, and the last documented check of the alarm system was several weeks before the incident. The secondary alarm at the nurse's station was faint and likely went unnoticed. The lack of a completed elopement risk assessment upon admission, absence of a care plan for elopement risk, and failure to ensure the functionality of the door alarm system contributed to the resident's unsupervised exit and subsequent fall.
Failure to Follow Infection Control Protocols During Catheter Care
Penalty
Summary
The facility failed to ensure proper infection control measures were followed during catheter care for a resident with an indwelling catheter and a history of dementia, benign prostatic hyperplasia, and obstructive and reflux uropathy. The resident required significant assistance with activities of daily living and was frequently incontinent of bowel. During an observation, a CNA provided peri and catheter care using the same wash cloths for both the resident's frontal peri area and backside, where there had been a bowel movement. Additionally, the CNA did not change gloves during the care process and touched multiple items in the resident's environment, including the bed control, sheets, the resident's head, and pillow, with soiled gloves. The CNA confirmed in an interview that she did not change gloves until after care was completed and used the same wash cloths for both areas. Facility policy required hand hygiene at key points, including after contact with body fluids or contaminated surfaces and after removing gloves, but these procedures were not followed.
Improper Pre-Pouring of Medications by Agency Nurse
Penalty
Summary
The facility failed to ensure that medications were not pre-poured prior to administration, affecting eight residents on the 200 hall. During an observation, it was noted that an LPN, who was an agency nurse, had pre-filled medication cups for the morning doses of these residents. Upon interview, the LPN confirmed that she pre-poured the medications and was unsure if this practice was allowed at the facility, although she had done it at other facilities. The facility's policy on medication administration, dated February 23, 2024, explicitly states that medications may not be prepared in advance.
Failure to Follow Physician Orders for Weekly Weights
Penalty
Summary
The facility failed to adhere to physician orders for weekly weight monitoring and medication administration for three residents, leading to a deficiency. Resident #36, who was moderately cognitively impaired and at risk for weight loss, had missing weight records on several occasions following a hospitalization, which caused the weight order to drop off the system. The Registered Dietician confirmed the oversight, indicating a lapse in maintaining consistent weight monitoring as per the care plan. Similarly, Resident #16, who was cognitively intact and diagnosed with diabetes, renal insufficiency, and dementia, also had missing weight records on multiple dates. The care plan highlighted the resident's risk for weight loss, yet the facility did not consistently record the weights as ordered. Additionally, Resident #23, with diagnoses including heart failure and diabetes, was not weighed weekly as required, with some instances of refusal not documented. These failures were confirmed by the Registered Dietician and were part of a complaint investigation, indicating non-compliance with physician orders.
Medication Administration Error for Resident with Alzheimer's
Penalty
Summary
The facility failed to administer medications as ordered for Resident #32, who was moderately cognitively impaired and diagnosed with Alzheimer's disease. During a medication observation, an agency LPN was found to have taken a Folic Acid 880 micrograms (mcg) tablet from the bottle instead of the prescribed one milligram (mg) tablet. The LPN, who did not regularly work at the facility, stated that the closest available medication was the 880 mcg tablet and that the pharmacy had not sent the correct medication. She confirmed her intention to administer the 880 mcg tablet without taking further action to address the discrepancy. The facility's policy on medication administration requires that medications be administered in accordance with physician orders, which was not followed in this instance.
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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 Cincinnati
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Daniel Drake Center For Post-acute Care Llc | 0.5 mi | — | 0 | 0 |
| Harmony Court Rehab And Nursing | 2.1 mi | ★★★★★ | 22 | 1 |
| Woods Edge Rehab And Nursing | 2.3 mi | ★★★★★ | 21 | 1 |
| Clovernook Health Care And Rehabilitation Center | 2.7 mi | ★★★★★ | 27 | 0 |
| Mount Notre Dame Health Center | 3.1 mi | ★★★★★ | 0 | 0 |
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