Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Four Seasons Retirement Center during CMS and state inspections, most recent first.
Failure to notify the physician of significant changes in condition affected multiple residents. A resident with diabetes had repeated BG readings above ordered parameters without documented provider notification, and other residents with HTN, hip fracture, HF, and diabetes had multiple overnight weight gains or BG elevations above ordered thresholds without evidence the MD was notified. Interviews confirmed staff were expected to notify the provider and document the communication in the EHR, but the record lacked those notifications.
Failure to implement a fall-related care plan intervention: a resident with a recent hip fracture and fall risk had a care plan calling for a sign in the room to remind her to call for assistance with transfers, but repeated observations found no sign posted. After an unwitnessed fall with left wrist and hip pain, staff interviews confirmed the intervention should have been in place and that management was responsible for implementing it.
A resident with HTN and intact cognition had an order for atenolol 25 mg daily with instructions to hold the dose if SBP was below 100. The EHR showed the med was given several times despite SBP readings below the ordered parameter, and an RN stated vital signs were checked before meds and out-of-range meds should be held.
Failure to document ordered daily weights for two residents. One resident with HTN and a hip fracture and another resident with HF and DM had physician orders for daily day-shift weights using the same time, scale, and personal equipment, but multiple weights were missing from the clinical record. The DON stated the missing weights should have been documented and that the facility did not have a policy for obtaining resident weights or following physician orders.
Missing Order for Supplemental Oxygen: A resident with a history of pneumonitis, pneumonia, and respiratory failure was observed using continuous supplemental O2 in her room and in the dining room, including a concentrator set at 3 L/min and a portable O2 concentrator. However, the resident’s current physician orders did not include an order for supplemental O2, and an LPN stated that O2 use should be supported by physician orders with flow rate and care parameters.
Inaccurate transcription of NP medication order: A resident with HTN, anxiety, and depression was started on Lexapro after reporting her current antidepressant was not working. The psychiatry note and new order documented Lexapro 10 mg daily, but the EHR order and EMAR showed Lexapro 20 mg daily was given. Medical Records said the NP usually transcribed new orders and the nurse approved them, and the DON stated there was no policy for reviewing physician notes.
A resident with a history of UTI and sepsis was observed multiple times with an indwelling urinary catheter bag touching the floor, contrary to infection control standards. Staff interviews confirmed the bag should not contact the floor, and the facility's policy required adherence to infection prevention procedures, but these were not consistently followed.
A nurse crushed and administered an extended-release potassium chloride tablet to a resident without a physician's order and without providing education on the associated risks, despite facility policy and pharmacy guidelines prohibiting the crushing of extended-release medications.
A facility failed to obtain STAT labs for a resident with a history of fracture, anemia, kidney disease, and hypertension. Despite orders for immediate CBC and UA tests due to bloody urine, the lab tests were delayed, and staff interviews revealed inconsistencies in understanding the protocol for STAT labs.
The facility failed to ensure timely provision of physicians' notes for four residents during regulatory visits. Residents experienced delays ranging from one to two weeks in receiving signed documentation from their physicians, contrary to the facility's policy requiring timely signing and provision of orders and pertinent documents.
Failure to Notify Physician of Significant Blood Glucose and Weight Changes
Penalty
Summary
The facility failed to notify the physician of changes in condition for multiple residents related to elevated blood glucose levels and weight gains. Resident 9 had diabetes and was ordered to have blood glucose checked four times daily, with physician notification required for readings below 70 or above 300. The record lacked documentation that the physician was notified for numerous blood glucose readings above 300 across multiple dates, including readings as high as 443, 430, 404, and 389. Resident 2 had diagnoses including hypertension and a hip fracture and was ordered to be weighed daily, with physician notification required for a weight gain greater than 3 pounds overnight. The record lacked indication that the physician was notified when the resident gained 4.8 pounds overnight and later 6.4 pounds overnight. The DON stated the staff should have documented that the physician was notified of the resident's weight gain. Resident 1 had hypertension and was ordered to be weighed daily, with notification required for weight gain greater than 3 pounds overnight, greater than 5 pounds in one week, or greater than 5 pounds since admission. The record lacked indication that the physician was notified for multiple overnight weight gains, including 5.6 pounds, 5.4 pounds, 5.6 pounds, 11.4 pounds, and 3.8 pounds. Resident 3 had heart failure and diabetes and was ordered to have blood glucose checked before meals and at bedtime, with notification required for readings below 70 or above 400, and later ordered short-acting insulin three times daily with notification required for readings below 70 or above 350. The record lacked indication that the physician was notified for multiple elevated blood glucose readings above both thresholds, including readings of 509, 455, 439, 404, 392, 385, and 366. Staff interviews indicated nurses were expected to notify the provider and document the notification in the EHR, and the Medical Records Nurse stated there were no uploaded documents related to weight gain and only a few notifications related to high blood glucose levels.
Failure to Implement Fall-Related Care Plan Intervention
Penalty
Summary
The facility failed to implement a care planned intervention for a resident who was at risk for falls after a recent hospitalization for a fracture. Resident 2’s record showed an admission MDS dated 04/11/2026 indicating the resident was cognitively intact and had a diagnosis that included a hip fracture. The care plan, with a start date of 04/27/2026 and a revision date of 05/12/2026, identified the resident as at risk for falls related to gait and balance problems secondary to the recent fracture hospitalization and included an intervention to place a sign in the resident’s room to remind the resident that assistance was needed with transfers. After an unwitnessed fall in the resident’s room on 05/01/2026, the resident was found on the floor on her left side with visible injuries and complaints of left wrist pain and left hip pain, and she was sent to the local emergency room. The resident returned to the facility on 05/08/2026. During observations on 07/06/2026, 07/09/2026, and 07/09/2026, no sign was observed in the resident’s room or bathroom, despite the care plan intervention. Staff interviews indicated that after a fall, interventions were to be placed into effect and that management staff were responsible for putting the interventions in place in the resident’s room. The facility policy on falls stated that charge nurses are responsible to ensure interventions are implemented as discussed.
Failure to Follow Atenolol Hold Parameters
Penalty
Summary
The facility failed to follow a physician’s order for atenolol 25 mg given once daily for high blood pressure for one resident who was cognitively intact and had a diagnosis that included hypertension. The order, started on 06/24/2026, directed nursing staff to hold the medication when the resident’s systolic blood pressure was less than 100. The electronic health record showed the medication was administered on multiple occasions when the resident’s systolic blood pressure was below the ordered hold parameter, including readings of 97, 97, 88, 99, and 96. During interview, an RN stated that vital signs were obtained each morning, usually 30 minutes before medications were given, and that if anything was out of range, she would not administer the medication. The facility policy stated that vital signs should be obtained and recorded when applicable or per physician orders, and medications should be held when vital signs are outside the physician’s prescribed parameters.
Failure to Document Ordered Daily Weights
Penalty
Summary
The facility failed to follow physician's orders for obtaining daily weights for 2 of 3 residents reviewed for nutrition. One resident had diagnoses including hypertension and a hip fracture, and a physician's order dated 06/04/2026 directed staff to weigh the resident daily on day shift at the same time, on the same scale, and with the same personal equipment; the clinical record did not document weights on 06/21/2026 and 07/04/2026. Another resident had diagnoses including heart failure and diabetes, and an open-ended physician's order dated 06/10/2026 directed daily day-shift weights under the same conditions; the clinical record lacked documented weights on 06/10/2026, 06/11/2026, 06/12/2026, 06/21/2026, 07/01/2026, 07/02/2026, and 07/04/2026. During interviews, the DON stated the missing weights should have been documented and also stated the facility did not have a policy related to obtaining residents' weights or following physician's orders.
Missing Order for Supplemental Oxygen
Penalty
Summary
The facility failed to appropriately manage a resident’s respiratory needs for 1 of 1 resident reviewed for respiratory care. The resident was cognitively intact and had diagnoses including pneumonitis due to inhalation of food and vomit, pneumonia, and respiratory failure. During interview and observation, the resident stated she required supplemental oxygen, used oxygen at home before admission, and wore it all the time in the facility. She was observed with oxygen tubing in place under her nose and connected to an oxygen concentrator set at 3 liters per minute, and an undated humidifier bottle was attached to the concentrator. The resident was also observed in the dining room with oxygen tubing connected to a portable oxygen concentrator and later in her room with tubing attached to the concentrator set at 3 liters. Review of the resident’s current physician orders showed no order for supplemental oxygen. An LPN stated that residents using supplemental oxygen would have a physician order specifying the flow rate and parameters, along with orders for oxygen tubing care and humidifier care. The LPN also stated there was no indication on the 24-hour report that the resident required supplemental oxygen, and there were no physician orders in the clinical record indicating she used supplemental oxygen.
Inaccurate transcription of NP medication order
Penalty
Summary
The facility failed to verify the accuracy of a resident’s physician/NP order and assessment related to the resident’s medication regimen. Resident 2’s record showed the resident was cognitively intact and had diagnoses including hypertension, anxiety, and depression. A Psychiatry Initial Consult Note documented that the resident said her current depression medication was not working and that Lexapro 10 mg once daily was to be started, with new orders reflecting Lexapro 10 mg daily. However, a physician’s order dated 04/16/2026 through 05/04/2026 indicated Lexapro 20 mg daily, and the order was entered into the EHR by the Psychiatric NP. The April 2026 EMAR showed the resident received Lexapro 20 mg daily during that period. During interview, Medical Records stated the Psychiatric NP usually transcribed new orders and the nurse approved the order and sent it to the pharmacy, and the facility did not always review the NP’s notes after transcription. The DON stated the facility did not have a policy related to reviewing physician notes.
Failure to Maintain Proper Catheter Bag Positioning and Infection Control
Penalty
Summary
Staff failed to follow appropriate infection control guidelines for indwelling urinary catheter care for a resident with a history of urinary tract infection (UTI) and sepsis. Multiple observations showed the resident's catheter bag hanging inappropriately, with portions of the bag touching the floor and no barrier in place. On several occasions, the catheter bag was seen either hanging from a trash can or under a recliner, with up to half of the bag in contact with the floor. Staff interviews confirmed that the catheter bag should not be touching the floor, and corrective action was taken during one observation to reposition the bag. The resident required staff assistance for mobility and was observed to use the call light when needing help. The facility's policy required adherence to professional standards of practice and infection prevention procedures for catheter care. Despite this, the observed practices did not align with infection control standards, as the catheter bag was repeatedly found in contact with the floor, increasing the risk of contamination.
Crushing of Extended-Release Medication Without Physician Order
Penalty
Summary
A registered nurse (RN) prepared and administered medications to a resident, including Klor-Con M20 Extended-Release tablets, by crushing all large pills and mixing them with applesauce at the resident's request. The nurse did not provide education to the resident regarding the risks associated with crushing an extended-release tablet. The clinical record did not contain a physician's order authorizing the crushing of the Klor-Con M20 Extended-Release tablet for this resident. During an interview, the RN acknowledged that extended-release medications should not be crushed. The facility's pharmacy-provided 'Medications Not To Be Crushed' list and the facility's own policy both indicated that extended-release medications, such as Klor-Con, should not be crushed. Despite these guidelines, the medication was crushed and administered in this manner, contrary to established standards and facility policy.
Failure to Obtain STAT Labs for Resident
Penalty
Summary
The facility failed to obtain STAT (immediate) laboratory tests for a resident with a history of fracture, anemia, kidney disease, and hypertension. The resident had completed an antibiotic for a UTI and subsequently exhibited slightly bloody urine. Despite receiving a new order for a STAT CBC and UA, the lab tests were not conducted promptly. The resident's urine specimen was collected, but the blood draw for the CBC was delayed. Multiple progress notes indicated that the lab had not come to the facility to draw the blood or pick up the urine specimen within the expected timeframe. Interviews with facility staff revealed inconsistencies in understanding the protocol for STAT labs. The RN indicated that STAT labs should be done by the next morning, while the Nurse Practitioner expected them to be done the same day. Medical Records staff stated that STAT labs should be obtained within 3 to 4 hours, and if the lab couldn't come in that timeframe, the facility should either obtain the samples themselves or contact the physician. The facility's policy on scheduling and tracking labs was not followed, leading to a delay in obtaining the necessary lab results for the resident.
Delayed Physician Documentation for Resident Visits
Penalty
Summary
The facility failed to ensure that physicians' notes were provided in a timely manner for four residents during regulatory visits. Resident 13, who was moderately cognitively impaired with diagnoses including atrial fibrillation, hypertension, and renal disease, had a physician visit on 01/23/24, but the documentation was not signed and provided until 02/06/24. Similarly, Resident 18, who was cognitively intact and had a stroke and hemiplegia, had a physician visit on 01/16/24, but the documentation was not signed and provided until 02/04/24. Resident 5, who was cognitively intact with diagnoses including hypertension, cancer, a left humerus fracture, and a seizure disorder, experienced delays in documentation for two visits. The first visit on 01/23/24 had documentation provided on 02/06/24, and the second visit on 02/20/24 had documentation provided on 03/09/24. Resident 2, who was cognitively intact with diagnoses including fractures, hypertension, anxiety, and depression, had multiple visits with delayed documentation, including visits on 12/19/23, 01/16/24, 02/13/24, and 03/12/24, with documentation provided weeks later. Interviews with Medical Records and the DON revealed that the facility often received the physician's notes one to two weeks after the visits, which were then uploaded into the residents' clinical records. The facility's policy required orders and pertinent documents to be signed at the time of the physician's visit or per facility standards, which was not adhered to in these cases.
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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) |
|---|---|---|---|---|
| Hickory Creek At Columbus | 0.9 mi | ★★★★★ | 0 | 0 |
| Willow Crossing Health & Rehabilitation Center | 2.1 mi | ★★★★★ | 14 | 0 |
| Silver Oaks Health Campus | 2.4 mi | ★★★★★ | 13 | 0 |
| Belmont Health & Rehabilitation, The | 6.7 mi | ★★★★★ | 0 | 0 |
| Miller's Merry Manor | 7.6 mi | ★★★★★ | 3 | 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 October 2026) and official state health department websites.