Below average — CMS composite of the measures below.
The next survey window likely opens around October 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 Magnolia Manor Of Columbus Nursing Center - East during CMS and state inspections, most recent first.
Hand hygiene was not followed during medication administration by three LPNs observed by surveyors. One LPN set up and administered medications without sanitizing her hands before or after resident contact, another entered a resident room and gave medications without hand hygiene before setup or between residents, and a third did not sanitize before setup and then removed gloves and gave oral medication without cleaning her hands. The DON stated staff are expected to use appropriate hand hygiene during medication pass and that infection control training is provided upon hire.
A resident room had a PTAC unit with a pull-out filter covered in a gray, flaky substance on repeated observations. The IMD confirmed the buildup and stated the filter cleaning task should have been completed, noting that PTAC units should be kept clean.
A resident with severe cognitive impairment and significant physical limitations required two-person assistance for bed mobility per their care plan. A CNA provided care alone, resulting in the resident falling from the bed and sustaining a head injury. Documentation and staff interviews confirmed the care plan was not followed.
A resident with severe cognitive impairment and significant physical limitations, requiring two-person assistance for bed mobility and personal care, was injured when a CNA provided care alone and the resident fell from the bed, sustaining a head injury. Staff interviews confirmed the care plan was not followed, leading to the accident.
The facility did not maintain an effective pest control program, as evidenced by repeated documentation of mice and roach sightings in multiple resident rooms over several months, ongoing complaints from residents and families, and confirmation from maintenance staff of a persistent infestation despite policy and monitoring efforts.
A facility failed to submit a PASRR Level II for a resident after a new bipolar disorder diagnosis was added. The resident was admitted without a significant mental health diagnosis, and the PASRR Level I did not include the bipolar diagnosis. The Social Service Director was responsible for submitting the PASRR Level II but did not do so, which could prevent the resident from receiving necessary services.
A resident with a care plan requiring weekly weights due to weight fluctuations was not weighed after 5/29/2024, as confirmed by the DON. The oversight was due to miscommunication between the lead CNA and restorative nursing, who were responsible for adjusting weight monitoring schedules during PAR meetings.
A facility failed to complete an admission nutrition assessment for a resident with type 2 diabetes, chronic kidney disease, and Alzheimer's disease, despite having specific dietary orders. The facility's policy requires such assessments upon admission, but the registered dietitian did not complete it, and the Interdisciplinary Team did not ensure its completion, leading to a deficiency.
The facility failed to administer oxygen therapy according to physician orders for two residents and did not maintain respiratory equipment in a sanitary manner for another resident. One resident received oxygen at a higher flow rate than ordered, while another's care plan did not reflect the physician's orders, leading to incorrect oxygen administration. Additionally, a resident's oxygen concentrator had a dirty filter, which staff acknowledged should be cleaned regularly.
The facility failed to administer the Pneumococcal vaccine to three residents, despite having obtained informed consent. The facility's policy requires offering the vaccine upon admission and documenting its administration, but there was no evidence of the vaccine being given to these residents. The DON confirmed that the process involves the assigned nurse administering the vaccine and documenting it in the eMAR, overseen by the Infection Preventionist. However, the DON could not find evidence of the vaccine administration, indicating a lapse in the vaccination process.
A resident with type 2 diabetes was scheduled for a vascular procedure and had orders to hold insulin on the day of the procedure. Despite this, nursing staff administered Novolog and Lantus insulin due to a computer input error that incorrectly set the hold time. The DON confirmed the error, which led to the administration of insulin against the physician's orders.
A resident with type 2 diabetes did not receive insulin and blood sugar monitoring as ordered. Despite instructions to hold insulin on the day of a procedure, nursing staff administered insulin due to a computer error. Additionally, the facility failed to schedule or obtain bedtime blood sugar readings until after a surveyor's inquiry.
A facility failed to include a resident's COVID-19 positive status in its infection control surveillance records, despite policies requiring such documentation. The resident, at high risk for complications due to hypertension, was asymptomatic and stable but was not tracked in the facility's infection control logs. The DON confirmed the resident and her roommate tested positive, yet the resident's status was not recorded as required.
Hand Hygiene Not Followed During Medication Pass
Penalty
Summary
The facility failed to ensure that infection control hand hygiene practices were followed by three of three LPNs observed during medication administration. The facility policy titled Infection Prevention and Control, last revised February 2021, stated that the facility is to maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment and to prevent the development and transmission of disease and infection, and that staff are required to wash their hands after each direct resident contact. During observation on 10/2/2025, LPN BB prepared and administered medications on the North 2 Low cart without performing hand hygiene before setting up the medications or after exiting a resident room, and then pushed the medication cart outside another resident's room and began setting up medications without hand hygiene. LPN CC prepared and administered medications on the North 2 High cart without sanitizing her hands before setting up medications, entered a resident's room, and administered the medications; she later confirmed she did not sanitize her hands before setting up medications or between residents. LPN AA did not perform hand hygiene before setting up medications, entered a resident's room with medications including two eyedrops, completed hand hygiene, applied gloves, administered an eyedrop into each eye, removed her gloves, and then gave oral medication without sanitizing her hands. The DON stated that the expectation during medication pass is that staff use appropriate hand hygiene and confirmed that everyone is trained on infection control upon hire.
Dirty PTAC Filter in Resident Room
Penalty
Summary
The facility failed to maintain a clean and comfortable environment in one resident room when the self-contained wall-mounted air conditioning unit (PTAC) had heavy gray, flaky substance buildup on the pull-out filter. Observations of room [ROOM NUMBER] on 9/30/2025, 10/1/2025, and 10/2/2025 each showed the PTAC filter covered with the same gray, flaky substance. During an interview on 10/2/2023 at 12:50 pm, the Interim Maintenance Director confirmed the PTAC unit had a gray flaky substance on the filters and stated that the filter cleaning task should have been completed on 9/30/2025 and that all PTAC models should be maintained in a clean condition.
Failure to Follow Two-Person Assist Care Plan Results in Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to implement a resident's care plan requiring two-person assistance for bed mobility. The resident, who had diagnoses including spinal cord disease, rheumatoid arthritis, and cervical spondylosis with myelopathy, was severely cognitively impaired and dependent on staff for most activities of daily living. The care plan specified that two staff members were needed for bed mobility due to the resident's physical limitations and chronic pain. Despite this, a Certified Nurse Aide (CNA) provided care alone and attempted to turn the resident without assistance. During this solo care, the resident fell from the bed, resulting in a hematoma and laceration to the head, necessitating transfer to the emergency room. Documentation and interviews confirmed that the CNA did not request help before the incident, and the care plan's requirements were not followed. The Director of Nursing and the Administrator both stated that staff were expected to adhere to care plans, especially for residents requiring extensive assistance.
Failure to Follow Two-Person Assist Care Plan Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) failed to follow the established plan of care for a resident who required extensive assistance with activities of daily living due to conditions such as disease of the spinal cord, rheumatoid arthritis, and spondylosis with myelopathy. The resident was documented as needing two-person assistance for bed mobility, turning, repositioning, and use of a bedpan, as well as being severely cognitively impaired and dependent on staff for most care. Despite these documented needs, the CNA provided care alone, without the required second staff member present. During the provision of care, the CNA attempted to turn the resident onto her left side and, while cleaning her, the resident rolled off the bed, resulting in a fall that caused a hematoma and laceration to the right side of the head. The incident required the resident to be transferred to the emergency room for further evaluation. Interviews with facility staff confirmed that the CNA did not request assistance as required by the care plan, and the Director of Nursing and Administrator both stated that staff are expected to follow care plans for residents needing extensive assistance.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective, facility-wide pest control program for its population of 89 residents. Review of the pest control policy and resident council minutes revealed ongoing concerns about rodents and insects, with repeated complaints and documentation of pest sightings over several months. The pest control checklist documented multiple instances of mice and roaches in various resident rooms across different units, with frequent sightings particularly on the South 2 unit. Residents and their families reported seeing rodents, and these concerns were discussed in resident council meetings as both unresolved and ongoing issues. Interviews with facility maintenance leadership confirmed that the facility had been experiencing an infestation of field mice and had recently changed pest control contractors, with an intensive eradication effort and increased monitoring. Despite these efforts, the pest control checklist continued to show recurring sightings of mice and insects in resident rooms over several months. During the survey, residents who had previously witnessed mice reported that it had been a couple of weeks since the last sighting, and no pests were observed by surveyors during their visit.
Failure to Submit PASRR Level II for New Mental Health Diagnosis
Penalty
Summary
The facility failed to submit a Preadmission Screening and Resident Review (PASRR) Level II for a resident after a new mental health diagnosis of bipolar disorder was added. The resident was initially admitted without a significant mental health diagnosis, and the PASRR Level I did not include the bipolar diagnosis. The resident's annual Minimum Data Set (MDS) later documented the bipolar disorder, but no PASRR Level II evaluation was conducted. Interviews revealed that the Social Service Director (SSD) was responsible for submitting PASRR Level II when a new serious mental illness diagnosis was added. However, the SSD did not submit the necessary documentation after the bipolar diagnosis was added. The Director of Nursing (DON) confirmed that this oversight could prevent residents from receiving necessary services for serious mental illnesses, potentially impacting their clinical and psychosocial condition.
Failure to Follow Care Plan for Resident Weights
Penalty
Summary
The facility failed to adhere to the comprehensive care plan for a resident, identified as R82, who was supposed to be weighed weekly due to weight fluctuations. The care plan, which was developed by the Interdisciplinary Team, included this intervention starting from 5/15/2024. However, the last recorded weight for R82 was on 5/29/2024, and no subsequent weekly weights were documented. This oversight was confirmed by the Director of Nursing (DON) during an interview, who acknowledged that the care plan required weekly weights as a nutrition intervention. The deficiency occurred due to a miscommunication between the lead Certified Nursing Assistant (CNA) responsible for weekly weights and the restorative nursing team responsible for monthly weights. The DON explained that R82 was initially placed on weekly weights due to weight fluctuations, and this was discussed in Performance and Accountability Reporting (PAR) meetings. Once R82's weights stabilized, the PAR team decided to switch to monthly weights, but the transition was not properly communicated. The lead CNA admitted to possibly missing the communication to the restorative nursing team, resulting in R82 not being added to the monthly weight list after the last recorded weight.
Failure to Complete Admission Nutrition Assessment
Penalty
Summary
The facility failed to complete an admission nutrition assessment for a resident, identified as R82, which is a requirement according to the facility's policy titled 'Scope of Assessments.' This policy mandates that nutritional assessments be completed upon admission, at least quarterly, and as needed based on the resident's condition and dietary needs. R82 was admitted with diagnoses including type 2 diabetes, chronic kidney disease stage 3, and Alzheimer's disease, and had specific dietary orders including a controlled carbohydrate diet and a renal diet, along with a Prostat nutrition supplement for low albumin and total protein levels. However, a review of the medical record revealed that an admission nutrition assessment was not completed by the registered dietitian or nursing staff. Interviews with the Director of Nursing (DON) confirmed the absence of the admission nutritional assessment in the medical record, which meant that nursing staff were unable to review dietary guidance for R82. The DON expected the registered dietitian to complete the assessment shortly after admission, and it was revealed that the Interdisciplinary Team (IDT) is responsible for reviewing new admission medical records to ensure all assessments are completed. The IDT should have notified the registered dietitian to complete the assessment, but this did not occur, leading to the deficiency.
Oxygen Therapy Administration and Equipment Maintenance Deficiencies
Penalty
Summary
The facility failed to administer oxygen therapy according to physician orders for two residents, R5 and R59, and did not maintain respiratory equipment in a sanitary manner for another resident, R11. R5, who had diagnoses including chronic pulmonary edema and chronic respiratory failure, was observed receiving oxygen at a flow rate of 3.5 liters per minute, contrary to the physician's order of 2 liters per minute. The Registered Nurse (RN) confirmed the discrepancy and acknowledged that the flow rate should be checked every shift. The Director of Nursing (DON) also confirmed that the flow rate should match the physician's order. R59, who had moderate cognitive impairment and was recently admitted to hospice services, was observed receiving oxygen at 4 liters per minute, despite a physician's order for 2 liters per minute. The RN confirmed the incorrect flow rate and acknowledged the order in the electronic medical record (EMR) was for 2 liters per minute. The DON stated that the care plan should be updated to reflect the physician's orders to prevent respiratory distress and ensure proper care. For R11, the facility failed to maintain the oxygen concentrator in a sanitary condition. The external filter on R11's oxygen concentrator was observed to be visibly dirty with accumulated dust. The Licensed Practical Nurse (LPN) and the DON both acknowledged the dirty filter and confirmed that it was the nursing staff's responsibility to clean the filters weekly and as needed. The DON emphasized that the exterior filter should always be clean to ensure proper respiratory care.
Failure to Administer Pneumococcal Vaccine Despite Obtained Consent
Penalty
Summary
The facility failed to ensure the administration of the Pneumococcal vaccine to three residents, despite having obtained informed consent for the vaccination. The facility's policy on Infection Prevention and Control mandates that each resident or their representative must receive education about the benefits and potential side effects of the Pneumococcal immunization, and that the vaccine should be offered upon admission. Additionally, documentation is required to confirm whether the resident received the immunization. However, for residents R12, R13, and R16, there was no evidence in their clinical records that the vaccine had been administered, even though consent forms were signed and dated. Interviews with the Director of Nursing (DON) revealed that the process for administering the vaccine involves the assigned nurse offering and administering the vaccine once consent is obtained, with documentation to be recorded on the electronic Medication Administration Record (eMAR). The Infection Preventionist, who is the Assistant Director of Nursing, is responsible for overseeing this process, with unit managers assisting in obtaining consent and communicating with the assigned nurse. Despite these procedures, the DON was unable to find evidence of the vaccine administration for the three residents, indicating a lapse in the facility's vaccination process.
Medication Administration Error for Diabetic Resident
Penalty
Summary
The facility failed to ensure that medications were administered as care planned and ordered for a resident with type 2 diabetes mellitus. The resident had a nutrition care plan that included an intervention for nursing staff to administer medication as ordered. However, on the day of a scheduled vascular procedure, the facility's nursing staff administered insulin despite pre-operation orders to hold diabetic medications. The orders to hold insulin were documented in the resident's electronic Medication Administration Record (eMAR), but the nursing staff administered 6 units of Novolog insulin at 11:30 am and 4:30 pm, and 30 units of Lantus insulin at 12:00 pm on the day of the procedure. The Director of Nursing (DON) acknowledged that there was an error in the computer input regarding the hold order for insulin. The hold was incorrectly set from 12 am to 10 am instead of for the entire day, leading to the administration of insulin contrary to the physician's orders. This error in medication administration had the potential to prevent the resident from receiving care in accordance with their care needs.
Failure to Administer Insulin and Monitor Blood Sugar as Ordered
Penalty
Summary
The facility failed to ensure that medications were administered and fingerstick blood sugar levels were obtained as ordered by the physician for a resident with type 2 diabetes mellitus. The resident had physician's orders for Novolog and Lantus insulin, which were not followed correctly on the day of a scheduled vascular procedure. Despite pre-operation instructions to hold insulin on the day of the procedure, the nursing staff administered both Novolog and Lantus insulin at various times on that day due to a computer input error. The error occurred because the hold order was incorrectly set to expire at 10 am instead of covering the entire day. Additionally, the facility did not adhere to the physician's order to obtain fingerstick blood sugar levels before meals and at bedtime. While the blood sugar levels were recorded at 6:00 am, 11:30 am, and 4:30 pm, there was no evidence of a bedtime reading being scheduled or obtained until after the surveyor's inquiry. This oversight was confirmed by the Director of Nursing, who acknowledged the absence of a scheduled bedtime reading on the electronic Medication Administration Record.
Inadequate COVID-19 Surveillance in Infection Control Program
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by the omission of a resident's COVID-19 positive status from the infection control surveillance records. The facility's policies required maintaining a record of incidents and corrective actions related to infections, as well as keeping a log of all resident and employee testing. However, despite documentation in the clinical record indicating that a resident tested positive for COVID-19, this information was not included in the facility's infection control surveillance logs or the specific COVID-19 tracking log. The resident, who was at high risk for COVID-19 complications due to hypertension, tested positive for COVID-19 and was documented as asymptomatic with stable vital signs. Despite this, the resident's positive test result was not recorded in the facility's infection control logs, and there was no evidence of a COVID-19 testing sheet for the resident's positive test. The Director of Nursing confirmed that the resident and her roommate both tested positive and remained in the same room, yet the resident's positive status was not tracked as required by the facility's infection control program.
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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) |
|---|---|---|---|---|
| Magnolia Manor Of Columbus Nursing Center - West | 0.1 mi | ★★★★★ | 3 | 0 |
| Parkwood Health Care Facility | 3.6 mi | ★★★★★ | 8 | 0 |
| Spring Harbor At Green Island | 4 mi | ★★★★★ | 9 | 0 |
| River Towne Center | 4.3 mi | ★★★★★ | 8 | 0 |
| Bridgeway Health And Rehabilitation Center | 4.3 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 July 2026) and official state health department websites.