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The next survey window likely opens around December 2026
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 Violet Springs Health Campus during CMS and state inspections, most recent first.
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.
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 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 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.
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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 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 | — | 27 | 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 | — | 18 | 1 |
| Canal Winchester Care Center | 4.8 mi | — | 17 | 0 |
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