Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 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 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.
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.
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 | — | 13 | 1 |
| Woods Edge Rehab And Nursing | 2.3 mi | — | 5 | 1 |
| Clovernook Health Care And Rehabilitation Center | 2.7 mi | — | 16 | 0 |
| Mount Notre Dame Health Center | 3.1 mi | — | 0 | 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.