Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Silver Oaks Health Campus during CMS and state inspections, most recent first.
A resident with dementia and osteoporosis was given another resident’s evening medications when a QMA, distracted while using a medication cart for the first time, mixed up two cups of pills for residents in nearby rooms and failed to follow the facility’s five-rights medication policy. The resident, who was ordered cholesterol and dementia medications at bedtime, instead received another resident’s seizure and diabetic medications, and a family member also reported that staff had previously attempted to perform a blood sugar test on this non-diabetic resident that was intended for a different patient.
A resident with severe cognitive impairment and dependent on staff for care fell from bed during a dressing change, resulting in a tibia/fibula fracture. The fall occurred as the resident was on an air mattress without side rails, and staff were not present on both sides of the bed. The facility lacked a specific policy for turning residents, contributing to the incident.
A resident with quadriplegia sustained a second-degree burn on the left foot after a CNA, who was not trained in using a blow dryer for foot care, dried the resident's feet at the resident's request. The CNA was unaware that the resident could not feel her feet, leading to redness and blisters. The facility's policy on change in condition and the risks associated with heating appliances for residents with paralysis were not adequately addressed.
A resident was served a meal that did not comply with her prescribed mechanical soft diet. Despite the meal ticket indicating the correct diet, the resident received a regular diet meal. The error was confirmed by the RN, Speech Therapist, and Dietary Manager, highlighting a lapse in following dietary orders.
A resident did not receive the prescribed 2 mg dose of Coumadin from 04/26/24 through 04/28/24, despite physician orders. Interviews with nursing staff revealed a lack of clarity and communication regarding the medication orders, and the facility's medication administration policy was not followed.
The facility failed to provide adequate bathing for two dependent residents, who were severely cognitively impaired and had multiple diagnoses. Resident C received only 6 out of 20 scheduled showers or complete bed baths, while Resident D received only 7 out of 11 scheduled showers or complete bed baths. Staff interviews and record reviews revealed significant gaps in the provision and documentation of bathing, contrary to the facility's policies.
The facility failed to hold a resident's blood pressure medication when the heart rate was below the physician's hold parameters. Despite instructions to hold the medication if the heart rate was less than 60, the resident received the medication on multiple occasions when the heart rate was below this threshold.
The facility failed to identify and document a resident's pressure ulcers in a timely manner. The resident, who was at high risk for pressure ulcers, revealed sores on his bottom that were not present upon admission. Staff interviews indicated a lack of communication and awareness regarding the resident's wounds, and the facility's policy on skin observation was not followed.
Wrong-Resident Medication Administration Due to Failure to Follow Five Rights
Penalty
Summary
The deficiency involves a failure to follow the facility’s medication administration guidelines, specifically the five rights of medication administration, resulting in a resident receiving another resident’s medications. A family member reported that while visiting Resident D, a staff member attempted to perform a blood sugar test related to insulin use, even though Resident D was not diabetic and had never been on insulin; the family member stopped the staff member from performing the test. Later, the same family member was notified that Resident D had received the wrong medications. Resident D’s clinical record showed moderate cognitive impairment with diagnoses including osteoporosis and dementia, and the EMAR indicated that at the 9:00 P.M. medication pass the resident was to receive atorvastatin, donepezil, and Zetia. During an interview, QMA 2 stated that on the night in question she was using the 200 Hall medication cart for the first time and was distracted by another resident talking to her while at the cart. She had two cups of pills prepared, one with two medications and one with three medications, for residents in nearby rooms, Resident D and Resident E. After administering medications to Resident D, she realized at the cart that she had given Resident D Resident E’s 9:00 P.M. medications instead of Resident D’s ordered medications. Resident E’s EMAR showed that the 9:00 P.M. medications included Keppra 500 mg and metformin 1000 mg, each ordered twice daily between 6:00 A.M.–10:00 A.M. and 6:00 P.M.–10:00 P.M. The facility’s written policy required verification of the right resident, right drug, right dose, right route, and right time with a triple check at three steps in the preparation process, which was not followed in this incident.
Failure to Prevent Resident Fall Resulting in Fracture
Penalty
Summary
The facility failed to prevent a fall during care that resulted in a fracture for a resident who was severely cognitively impaired and dependent on staff assistance for all care. The resident was lying on an air mattress without side rails or grab bars, and the bed was positioned by the door. During a dressing change, the resident rolled off the bed between the wall and the bed, resulting in a bruise and skin tear on the right forearm. Initially, first aid was applied, and the resident showed no immediate signs of pain or discomfort. Subsequent observations revealed discoloration and warmth in the resident's right shin, leading to an x-ray that confirmed an acute distal tibia/fibula fracture. The resident was then sent to the emergency room for splinting and later returned to the facility with instructions to remain non-weight bearing and to follow up with an orthopedic surgeon. Interviews with staff indicated that the air mattress was set to a firm setting during the dressing change, which may have contributed to the instability that led to the fall. The facility lacked a specific policy for turning residents in bed, and staff were trained to turn residents side to side based on the type of care being provided. The incident highlighted a failure to maintain a hazard-free environment and implement preventative measures, as outlined in the facility's Fall Management Program Guidelines. The deficiency was identified as part of a complaint investigation.
Removal Plan
- Educate nurses and aides on turning and repositioning resident dependent on staff.
- Educate staff on accident hazards related to air mattress, bed mobility, and falls.
- Conduct return demonstration of proper rolling/turning/repositioning techniques.
Resident Sustains Second-Degree Burn Due to Improper Foot Care
Penalty
Summary
The facility failed to ensure a resident did not acquire a burn during care, resulting in Resident B sustaining a second-degree burn on the left foot. Resident B, who was cognitively intact and had diagnoses including traumatic spinal cord dysfunction and quadriplegia, required extensive staff assistance with all ADLs. The resident's clinical record lacked documentation of an order or care plan related to the use of a blow dryer to dry the resident's feet. On the day of the incident, CNA 2, who had not been trained on using a blow dryer on the resident's feet, dried Resident B's feet at the resident's request. The resident's left foot became red, and blisters later formed, leading to a diagnosis of second-degree burns on the left toes by the wound center. Interviews revealed that the CNA was unaware that the resident could not feel her feet, and the facility's policy on notification of change in condition was not adequately followed in this case. The incident was documented in progress notes and interviews with the resident, CNAs, LPN, and NP. The resident had been having her feet dried with a blow dryer for a long time, as recommended by her podiatrist, but this was the first time CNA 2 had assisted her. The CNA noticed the redness after drying the feet and informed LPN 3, who then notified the DON. The resident's condition was monitored, and treatment was provided, but the lack of proper training and awareness among staff contributed to the incident. The facility's policy on change in condition and the risks associated with heating appliances for residents with paralysis were not adequately addressed, leading to the deficiency.
Failure to Follow Resident's Diet Order
Penalty
Summary
The facility failed to follow a resident's diet order for a mechanical soft diet. During an observation, Resident C was served a lunch plate that did not comply with her prescribed mechanical soft diet. The meal ticket indicated a mechanical soft diet, but the resident was served a regular diet meal consisting of a slice of ham, cheddar hashbrowns, roasted carrots, and a piece of cake. RN 6 confirmed that the resident's diet order in the clinical record was for a mechanical soft diet, which had not been updated by the kitchen. The Speech Therapist also confirmed that the resident should have been served a mechanical soft meal and ordered the correct diet from the kitchen. The Dietary Manager indicated that the cook working in the 600 Hall kitchen was unfamiliar with the residents' diet orders and that the aides should have checked the meal tickets to ensure the correct diet was served. Resident C's diet order, which started on 04/10/24, indicated a mechanical soft diet with extra gravy and no straws. The resident was severely cognitively impaired and had multiple diagnoses, including metabolic encephalopathy, hypertension, heart failure, diabetes, malnutrition, anxiety, and depression. The resident had episodes of coughing or choking during meals or when swallowing medications and had complaints of difficulty or pain with swallowing. The facility's policy on Resident Dining & Nutritional Preferences emphasized the importance of following dietary orders to meet residents' nutritional needs, but this policy was not adhered to in this instance.
Failure to Follow Physician Orders for Blood Thinner Administration
Penalty
Summary
The facility failed to follow physician orders related to the administration of a blood thinner, Coumadin, for a resident. The resident, who was cognitively intact and had diagnoses including fracture, anemia, atrial fibrillation, and hypertension, was observed to be in good condition with no visible bruises or bleeding. However, a review of the clinical records revealed discrepancies in the administration of Coumadin. Specifically, the resident was supposed to receive a 2 mg dose of Coumadin from 04/26/24 through 04/28/24, but this dose was not administered as per the physician's orders. Interviews with the nursing staff, including an RN and the Director of Nursing (DON), indicated a lack of clarity and communication regarding the resident's medication orders. The RN explained the process for obtaining and communicating PT/INR results and coordinating with the physician for any dose changes. Despite this process, the 2 mg dose of Coumadin was not administered as ordered. The DON was unable to explain why the dose was discontinued, despite the order to continue it. The facility's policy on medication administration, which mandates that medications be administered as prescribed, was not followed in this instance.
Failure to Provide Adequate Bathing for Dependent Residents
Penalty
Summary
The facility failed to provide adequate bathing for two dependent residents, Residents C and D, as required by their policies. Resident C, who was severely cognitively impaired and had multiple diagnoses including metabolic encephalopathy, hypertension, heart failure, diabetes, malnutrition, anxiety, and depression, received only 6 out of 20 scheduled showers or complete bed baths since admission. There was only one documented refusal of a scheduled shower or complete bed bath for Resident C. Similarly, Resident D, also severely cognitively impaired with diagnoses including metabolic encephalopathy, anemia, diabetes, and malnutrition, received only 7 out of 11 scheduled showers or complete bed baths from admission until discharge. There was a lack of documentation for one of the scheduled bathing sessions for Resident D. Interviews with facility staff revealed that residents were to be offered showers at least twice a week, with the option for more if requested. The staff were required to document the bathing in the electronic record and fill out a skin sheet after each bath, which was then signed by the nurse and given to the ADON. However, the records for both residents showed significant gaps in the provision and documentation of bathing, indicating a failure to adhere to the facility's policies on bathing and ADL documentation.
Failure to Hold Blood Pressure Medication as Per Physician's Orders
Penalty
Summary
The facility failed to hold a resident's blood pressure medication when the resident's heart rate was outside of the physician's hold parameters. Resident E, who was severely cognitively impaired and had diagnoses including senile degeneration of the brain, anemia, diabetes, heart failure, and hypertension, was prescribed metoprolol succinate with instructions to hold the medication if the heart rate was less than 60. Despite this, the medication was administered on multiple occasions when the resident's heart rate was below the specified threshold. The clinical record review revealed that Resident E received the medication on several dates in March and April 2024 when the heart rate was below 60, with the lowest recorded heart rate being 45. During an interview, an LPN confirmed that the heart rate should be checked before administering the medication and that the medication should not be given if the heart rate is outside the parameters, with the Nurse Practitioner being notified in such cases. The facility's policy on medication administration supports this procedure, indicating that medications should be administered according to the prescriber's written orders.
Failure to Identify and Document Pressure Ulcers
Penalty
Summary
The facility failed to identify and properly document a pressure ulcer for Resident D, who was at high risk for pressure ulcers. During an observation, the resident revealed sores on his bottom that were not present upon admission. The sores included small open areas on the coccyx and buttocks, which were pink in color with no drainage. The resident's clinical record indicated he was always incontinent of bowel and bladder and had no pressure ulcers at the time of admission. However, the record lacked documentation of the newly observed pressure ulcers. Interviews with staff revealed that the dressing had been removed earlier due to increased bowel movements, and there was a lack of communication among staff regarding the resident's wounds. The Qualified Medication Aide (QMA) and Certified Nurse Aide (CNA) working with the resident were unaware of the wounds. The Wound Care Nurse indicated that she relied on nurses and aides to inform her of any new skin issues, but the staff had not alerted her about the resident's condition before the areas became open wounds. The facility's policy on weekly skin observation required nurses and aides to monitor and report any skin impairments. Despite this policy, the staff failed to identify and document the resident's pressure ulcers in a timely manner. The Wound Care Nurse confirmed that the areas were not present on admission and should have been reported before they became open wounds. This deficiency was related to a complaint investigation.
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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.
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Nursing homes near Columbus
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willow Crossing Health & Rehabilitation Center | 0.5 mi | — | 14 | 0 |
| Four Seasons Retirement Center | 2.4 mi | — | 0 | 0 |
| Hickory Creek At Columbus | 2.7 mi | — | 7 | 0 |
| Belmont Health & Rehabilitation, The | 6 mi | — | 9 | 0 |
| Miller's Merry Manor | 8.1 mi | — | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.