Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Medicalodges Columbus during CMS and state inspections, most recent first.
A resident with dysphagia, oropharyngeal dysphagia, Alzheimer’s disease, and severe cognitive impairment had clear EMR orders and care plan directives for a mechanical soft diet with ground meat and specific food restrictions. Despite this, dietary staff served the resident a whole chicken strip instead of ground meat, contrary to both the physician’s orders and facility policies requiring meat on mechanical soft diets to be chopped, flaked, or ground. During the meal, the resident choked on the chicken, and staff in the dining room performed the Heimlich maneuver, dislodging the food. Staff interviews revealed that the facility had a diet-card and multi-step verification process for ensuring correct diet texture, but this process was not properly followed for the resident’s meal, leading to the choking incident that surveyors cited as Immediate Jeopardy.
The facility did not conduct annual performance reviews for two CNAs, employed for over a year, as required by the Employee Handbook. This was confirmed by an administrative nurse and could affect the quality of care provided to residents.
The facility failed to maintain an effective infection control program, with staff not performing proper hand hygiene and failing to use appropriate PPE during care activities. Instances included improper glove use during catheter and wound care, and lack of PPE during bed sheet changes. Interviews revealed non-adherence to infection control policies, posing potential cross-contamination risks.
The facility failed to maintain a functional emergency call system, with multiple instances of call lights being out of reach or malfunctioning. Staff interviews revealed inconsistent use of pagers, and maintenance checks showed persistent issues despite regular audits. Administrative staff were unaware of these problems, and the facility lacked a policy for emergency call light use.
The facility failed to accurately complete the MDS for several residents, leading to uncommunicated care needs. A resident with cognitive and physical impairments experienced falls that were not accurately documented, while another resident's continence status and restorative care were misrepresented. Additionally, a resident's antidepressant medication was not properly recorded, and another resident's fall history was inaccurately documented. These inaccuracies were confirmed by the administrative nurse, highlighting significant deficiencies in resident assessments.
The facility failed to implement and maintain fall prevention measures for several residents, leading to multiple falls. A resident with cognitive impairment was found without a call light within reach, and a transfer pole was missing. Another resident's call light system was non-functional, leaving them unable to request assistance. Additionally, a resident dependent on staff for transfers was not safely transferred, and their electric recliner was improperly managed. These deficiencies highlight the facility's failure to adhere to fall prevention protocols.
The facility failed to obtain informed consent for psychotropic medications for four residents with severe cognitive impairments, violating their policy. Despite receiving medications like Prozac, Xanax, Venlafaxine, Seroquel, Fluoxetine, Lorazepam, and Mirtazapine, the facility did not have signed consent forms. This oversight was confirmed by an administrative nurse, indicating a systemic issue in medication management.
A facility failed to implement a comprehensive care plan for a resident with Parkinson's disease, who was dependent on staff for transfers and had severe cognitive impairment. The care plan lacked instructions for the use of an electric recliner, despite the resident's fall risk and inability to operate it safely. Staff inconsistently followed the intervention to keep the recliner unplugged, leading to a fall incident. Additionally, the facility did not complete required assessments for the recliner's use, contributing to the deficiency.
The facility failed to update care plans for two residents after significant changes in their conditions. One resident experienced multiple falls, yet the care plan lacked consistent updates with necessary interventions, such as ensuring the call light was within reach and completing a CT scan. Another resident developed a stage two pressure ulcer, but the care plan inaccurately documented the use of a cushion, which was not present in the resident's seating. These deficiencies in care planning risked uncommunicated care needs.
A resident with Alzheimer's and peripheral vascular disease had toe abrasions and was instructed to wear non-skid socks until healed. Despite this, the resident was observed wearing shoes multiple times. Staff interviews confirmed the resident wore shoes daily, contrary to the care plan and physician's orders. The facility's policy required addressing footwear for residents with skin issues, but this was not followed, leading to a deficiency.
The facility failed to provide adequate care for two residents with pressure ulcers. One resident with Alzheimer's disease developed a stage II ulcer behind the left ear, and the required padding was often not in place. Another resident with multiple health issues had a stage II ulcer on the buttock, but did not have the necessary pressure-reducing cushion in their seating arrangements. The facility's policies on wound prevention and management were not effectively implemented, leading to these deficiencies.
The facility failed to notify providers when medications were held for two residents, leading to a deficiency. One resident with hypertension had multiple antihypertensive medications held without provider notification, while another resident with diabetes had insulin doses held without consistent notification. This lack of communication placed both residents at risk for adverse complications.
A resident with cerebral palsy and osteoporosis was injured during a mechanical lift transfer when a CNA attempted the transfer alone, contrary to facility protocol requiring two staff members. The CNA failed to secure a leg strap, causing the resident to fall and sustain a laceration, hematoma, and hip fracture.
Failure to Follow Mechanical Soft Diet Orders Resulting in Choking Episode
Penalty
Summary
The deficiency involves the facility’s failure to provide a resident with food in the physician-ordered mechanical soft, ground meat form. The resident had diagnoses of dysphagia, oropharyngeal phase dysphagia, and Alzheimer’s disease, with a BIMS score of four indicating severe cognitive impairment. Her MDS and CAAs documented that she coughed or choked during meals or when swallowing medications and that she required a mechanically altered diet. The care plan and EMR orders specified a regular diet with mechanical soft texture, ground meat with gravy or sauce (no dry meat), and multiple restrictions including no soft tortilla shells, no salad, no raw onions, no raw vegetables, and tortilla chips to be crushed or broken. An intervention also directed staff to cut up her food and remind her to take only one bite at a time. Despite these documented needs and orders, on the day of the incident the resident was served a whole chicken strip instead of ground meat. A nurse’s note recorded that the resident received a whole chicken strip for lunch and choked on a bite of chicken. Staff statements confirmed that dietary staff provided a whole chicken strip, and one dietary staff member stated he had chopped one up but then set it aside and gave her a whole chicken strip because he could not remember if they were supposed to be chopped for her. This action directly conflicted with the resident’s ordered mechanical soft diet with ground meat and the facility’s own policies requiring foods to be cut, chopped, or ground to meet individual needs and specifying that meat, fish, and poultry on mechanical soft diets should be chopped, flaked, or ground. When the resident began choking, another resident alerted staff in the dining room. Staff observed the resident choking, and a CNA and another staff member attempted and then performed the Heimlich maneuver, resulting in the resident expelling a chunk of food onto the floor and stating she felt better. A prior progress note also documented that the resident had experienced a possible choking episode in the dining room on an earlier date, during which she was observed coughing with blue lips, encouraged to cough up a moderate amount of mushy substance, and suctioned for a moderate amount of thick, clear mucus. The facility’s dietary and nursing staff interviews described an established process using diet cards and multiple verification steps to ensure correct diet texture and consistency, but staff acknowledged that this process was not thoroughly followed for this resident’s meal, resulting in her receiving a full chicken strip instead of the ordered mechanical soft, ground meat diet. This failure led to a choking episode that surveyors determined constituted Immediate Jeopardy.
Removal Plan
- Provide in-service education for dietary monitoring and ensuring proper diets are served to each resident for direct-care staff and kitchen staff
- Provide 1:1 education with the cook and dietary aide
- Implement disciplinary action for the cook and dietary aide
- Provide 1:1 in-service education with all staff who serve in the dining room
- Revise the dining room monitoring schedule to include manager coverage for all meals
- Verify all at-risk residents to ensure diets match their diet cards
- Provide RELIAS educational training for the cook
- Hold a QAPI meeting with the Director of Nursing, Administrator, and Medical Director
Failure to Conduct Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to conduct annual performance reviews for two Certified Nurse Aides (CNAs), identified as CNA M and CNA O, who had been employed for more than one year. This deficiency was identified during a review of five employee personnel files, which revealed that CNA M, hired on November 4, 2022, and CNA O, hired on November 27, 2023, did not have documented annual performance evaluations in their personnel files. This oversight was confirmed by Administrative Nurse D on February 10, 2025. The facility's Employee Handbook mandates that supervisors conduct performance evaluations for all full-time and part-time employees annually, a requirement that was not met for these two CNAs, potentially impacting the quality of care and services provided to the residents.
Infection Control Deficiency Due to Improper Hand Hygiene and PPE Use
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by improper hand hygiene and failure to follow enhanced barrier precautions (EBP) during care activities. On multiple occasions, staff members, including a Certified Medication Aide (CMA), Certified Nurse Aide (CNA), and Licensed Nurse (LN), did not perform proper hand hygiene after removing gloves and before putting on new ones. Specifically, during a catheter bag change for a resident, staff removed their gloves but did not sanitize their hands before continuing care. Additionally, a Licensed Nurse failed to perform hand hygiene and change gloves before placing a clean dressing on a resident's wound. The report also highlights instances where staff did not wear the appropriate personal protective equipment (PPE) when caring for residents requiring EBP. For example, a CNA did not wear the proper PPE while changing bed sheets after giving a resident a bed bath. Interviews with staff members revealed a lack of adherence to the facility's infection control policies, including the use of gowns and gloves for residents with catheters or wounds. The facility's Administrative Nurse confirmed the expectation for staff to follow EBP and perform hand hygiene as per policy, but these practices were not consistently followed, leading to potential cross-contamination risks.
Deficiency in Emergency Call System Functionality
Penalty
Summary
The facility failed to maintain a functional emergency call system, which is essential for residents to call for staff assistance from their rooms, bedside, bathroom areas, and bathing facilities. Observations revealed multiple instances where the emergency call lights were either out of reach for residents or malfunctioned. For example, one resident had their call light on the floor behind a table, making it inaccessible, while another resident's call light was placed on an over-bed table, out of reach. Additionally, a resident reported that the emergency call system did not always work, leading them to use their phone to call for assistance. Maintenance checks revealed that some call lights required multiple attempts to activate, and others in the shower room did not work at all. Staff interviews indicated a lack of consistent use of pagers, which are supposed to alert staff when a call light is activated. Some staff members admitted to not carrying pagers, and it was noted that the computer monitor displaying call light alerts was concealed by a curtain, limiting its visibility. Maintenance staff reported conducting monthly checks and random weekly audits of the call lights, but issues persisted, with staff sometimes removing pager batteries to avoid carrying them. Administrative staff were unaware of the ongoing issues with the call light system and the staff's reluctance to use pagers. The facility also failed to provide a policy for the use of emergency call lights.
Inaccurate MDS Completion Leads to Uncommunicated Care Needs
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for several residents, leading to uncommunicated care needs. Resident 15, who had a history of cognitive communication deficit, diabetes mellitus, coronary artery disease, hypertension, muscle weakness, and depression, was inaccurately assessed in relation to falls. Despite having experienced falls, the MDS did not reflect these incidents accurately, as confirmed by Administrative Nurse D. Observations revealed that R15 was found on the floor on multiple occasions, and during one observation, the resident was without a call light within reach, indicating a lack of proper fall prevention measures. Resident 1's MDS was also inaccurately completed concerning continence status and restorative care. The resident, diagnosed with spastic hemiplegia, bipolar disorder, and seizures, was documented as always incontinent, although records showed instances of continence. Additionally, the resident's care plan included a restorative program for an ankle-foot orthotic (AFO) and splint care, but observations and interviews revealed that the AFO was too small and not being used, contradicting the documented care plan. Administrative Nurse D confirmed these inaccuracies and noted that the program could not be completed as documented. Resident 18's MDS inaccurately documented the administration of antidepressant medication. Despite having a diagnosis of major depressive disorder and receiving venlafaxine, the MDS lacked documentation of this medication during the assessment period. Similarly, Resident 20's MDS inaccurately recorded a fall that did not occur after a specific date, as confirmed by Administrative Nurse D. The resident, diagnosed with Alzheimer's and Parkinson's disease, was at a high risk for falls, yet the MDS did not accurately reflect the resident's fall history, leading to potential uncommunicated care needs.
Failure to Implement and Maintain Fall Prevention Measures
Penalty
Summary
The facility failed to adequately implement and reevaluate fall prevention interventions for several residents, leading to multiple falls and placing residents at risk for injury. Resident 15, who had a history of cognitive impairment and multiple falls, was observed without a call light within reach on several occasions, and the transfer pole intended to assist him was not present in his room. Despite documented interventions in his care plan, such as ensuring the call light was within reach and moving his room closer to the nurse's station, these measures were not consistently followed, and new interventions were not implemented after each fall. Resident 17, who had severe cognitive impairment and a history of falls, was found to have a non-functioning call light system, which did not alert staff when activated. Despite the facility's policy to ensure call lights were within reach and functioning, the call light in Resident 17's room was not operational, and staff did not respond to the call light when it was activated. This failure to maintain a working call light system left Resident 17 without a reliable means to request assistance, increasing the risk of falls. Resident 20, who had severe cognitive impairment and was dependent on staff for transfers, was not safely transferred according to her care plan. The care plan required the use of a gait belt and specified that her electric recliner should remain unplugged to prevent her from operating it unsafely. However, staff left the recliner plugged in, and the resident was transferred without proper weight-bearing support. Additionally, the facility failed to complete necessary assessments for the resident's ability to safely use the electric recliner, further compromising her safety. Resident 18, also with severe cognitive impairment, was observed without a call light within reach, contrary to the care plan's instructions, which further exemplifies the facility's failure to adhere to fall prevention protocols.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for the use of psychotropic medications for four residents, which is a violation of their policy for Behavior Management and Psychotropic Medications. The policy, revised in November 2024, mandates that informed consent must be completed for the use of psychotropic medications that affect brain activity prior to their initial administration. Despite this requirement, the facility did not have signed and dated informed consent forms for Residents 12, 17, 18, and 30, all of whom were receiving psychotropic medications. Resident 12, who has severe cognitive impairment with a BIMS score of two, was receiving Prozac for depression and Xanax for anxiety. The resident's care plan required monitoring for side effects and notifying the physician of any adverse reactions. However, the facility did not have a signed informed consent for these medications. Similarly, Resident 18, with a BIMS score of four indicating severe cognitive impairment, was receiving Venlafaxine and Seroquel for depression and agitation, respectively, without a signed informed consent. Resident 17, also with severe cognitive impairment and a BIMS score of five, was receiving Fluoxetine for major depressive disorder without informed consent documentation. Resident 30, with diagnoses of anxiety, major depressive disorder, and insomnia, was receiving Lorazepam and Mirtazapine. The facility failed to document behaviors at the time of Lorazepam administration and did not have a signed informed consent for the use of these medications. Administrative Nurse D confirmed that informed consent forms were not completed and signed for these residents, highlighting a systemic issue in the facility's medication management practices.
Failure to Implement Comprehensive Care Plan for Resident Using Electric Recliner
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with Parkinson's disease, who was dependent on staff for transfers and had severe cognitive impairment. The resident's electronic medical record (EMR) indicated a history of falls and a moderate to high risk for future falls. Despite this, the care plan lacked specific instructions regarding the use of an electric recliner in the resident's room, which was a significant oversight given the resident's inability to safely operate the recliner due to physical and cognitive limitations. The deficiency was highlighted by an incident where the resident fell from the electric recliner, resulting in a reddened area on her spine. The interdisciplinary team had previously initiated an intervention to keep the recliner unplugged when the resident was seated to prevent her from raising the chair independently. However, observations revealed that staff frequently left the recliner plugged in, with the controller accessible to the resident, contrary to the intervention plan. This inconsistency in care practices contributed to the resident's fall risk. Interviews with staff members revealed a lack of clarity and adherence to the care plan regarding the recliner's use. Some staff members were unaware of the requirement to unplug the recliner, and there was no consistent practice in place. Additionally, the facility failed to complete an Electric Recliner Assessment upon the resident's admission and did not conduct regular assessments as required by their policy. This lack of assessment and clear guidance in the care plan contributed to the deficiency in providing safe and appropriate care for the resident.
Failure to Revise Care Plans for Falls and Pressure Ulcer Management
Penalty
Summary
The facility failed to accurately revise the care plans for two residents, R15 and R11, after significant changes in their conditions, leading to uncommunicated care needs. R15, who had a history of cognitive communication deficit, muscle weakness, diabetes mellitus, coronary artery disease, hypertension, and depression, experienced multiple non-injury falls. Despite these incidents, the care plan was not consistently updated with appropriate interventions. Observations revealed that R15's call light was often out of reach, and a transfer pole was missing from his room, which was confirmed to be on back order. Additionally, a CT scan ordered to check for suspected neurological deficits had not been completed, further indicating lapses in care plan updates. R11, diagnosed with diabetes mellitus, Parkinson's disease, morbid obesity, and chronic kidney disease, developed a stage two pressure ulcer. The care plan documented the use of a pressure-reducing mattress and a wheelchair cushion, but observations and interviews revealed that R11 did not have a cushion in his recliner, wheelchair, or motorized scooter. Despite the care plan's directives, R11 reported not using a cushion, and staff confirmed the absence of these essential items, indicating a failure to revise the care plan to reflect the resident's current needs. The facility's policies on falls management and wound prevention and management were not adhered to, as evidenced by the lack of appropriate interventions and updates to the care plans following the residents' falls and pressure ulcer development. This deficiency in care planning placed the residents at risk for uncommunicated care needs, potentially affecting their overall physical and psychosocial well-being.
Failure to Follow Care Plan for Resident with Toe Abrasions
Penalty
Summary
The facility failed to adhere to the care plan and physician's orders for a resident with skin abrasions on the toes. The resident, diagnosed with Alzheimer's disease and peripheral vascular disease, had abrasions on the second toe of the right foot and the second and third toes of the left foot. The care plan, revised on 01/05/25, instructed staff to leave the resident's shoes off and only have him wear non-skid socks until the abrasions healed. Despite this, observations on multiple occasions revealed the resident wearing white Velcro tennis shoes, contrary to the care plan and physician's orders. Interviews with staff members, including a Certified Medication Aide, Certified Nurse Aide, and Licensed Nurse, confirmed that the resident was wearing shoes daily, despite the care plan's instructions. The facility's policy for wound prevention and management required addressing footwear appropriateness for residents with skin integrity issues. The administrative nurse acknowledged that the abrasions were caused by ill-fitting shoes, which had been removed by the family, and confirmed the expectation for staff to refrain from putting shoes on the resident until the abrasions healed. This failure to follow the care plan and physician's orders resulted in a deficiency related to the resident's care.
Inadequate Pressure Ulcer Care for Two Residents
Penalty
Summary
The facility failed to provide adequate care for two residents with pressure ulcers, leading to deficiencies in their treatment and prevention. Resident 13, diagnosed with Alzheimer's disease and moderately impaired cognition, developed a stage II pressure ulcer behind the left ear. Despite physician orders to pad the earpiece of the resident's glasses and oxygen tubing to prevent further irritation, observations revealed that the padding was frequently not in place. Staff interviews confirmed the inconsistency in following the care plan, which was expected to be adhered to until the wound healed. Resident 11, with diagnoses including diabetes mellitus, Parkinson's disease, morbid obesity, and chronic kidney disease, was identified as having a stage II pressure ulcer on the buttock. The care plan required the use of a pressure-reducing cushion in the resident's wheelchair, recliner, and motorized scooter. However, observations and interviews indicated that the resident did not have a cushion in any of these seating arrangements. The resident reported discomfort with a cushion previously tried, and staff confirmed the absence of a cushion, which was contrary to the care plan. The facility's policies on wound prevention and management, as well as electronic care plans, were not effectively implemented, resulting in inadequate care for the residents' pressure ulcers. The failure to consistently apply necessary interventions, such as padding and pressure-reducing cushions, contributed to the deficiencies observed in the care of these residents.
Failure to Notify Providers of Held Medications
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary drugs, as evidenced by the administration of excessive doses of antihypertensive medications without proper provider notification. Resident 17, who had diagnoses including hypertension and dementia, experienced multiple instances where medications such as Diltiazem, Lisinopril, Metoprolol, and Clonidine were held without notifying the provider. This lack of communication occurred despite the presence of specific instructions to hold medications under certain conditions, such as low systolic blood pressure or pulse. The facility's electronic medical administration records (EMAR) showed numerous instances of these medications being held over several months without provider notification, placing the resident at risk for adverse complications. Additionally, Resident 134, who had diabetes mellitus, was at risk due to the facility's failure to notify the provider when insulin doses were held. The resident's care plan included instructions to hold insulin if blood sugar levels were below a certain threshold or if the resident did not eat. Despite these instructions, the EMAR revealed that Novolog insulin was held multiple times over a short period without consistent provider notification. The lack of communication with the provider about these held doses posed a risk for adverse complications related to the resident's diabetes management. Interviews with facility staff, including administrative and licensed nurses, indicated an expectation that providers should be notified whenever a medication is held. However, the facility lacked a formal policy on physician notification, contributing to the oversight. The failure to notify providers about held medications for both residents resulted in a deficiency, as it placed the residents at risk for future adverse complications due to the potential for unnecessary drug administration.
Resident Injury Due to Improper Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure the safety of a dependent resident, identified as R1, during a mechanical lift transfer. Certified Nurse Aide (CNA) M attempted to transfer R1 without the assistance of a second staff member, which was against the facility's protocol for mechanical lift transfers. During the transfer, CNA M did not secure one of the leg straps to the mechanical lift, resulting in R1 falling from the lift and sustaining injuries. R1, who had a history of cerebral palsy, osteoarthritis, and osteoporosis, was totally dependent on staff for activities of daily living and required a mechanical lift for transfers. The resident's care plan indicated a moderate risk for falls and required the use of a mechanical lift with two staff members present. Despite these instructions, CNA M proceeded with the transfer alone, leading to R1 falling face forward onto the floor. As a result of the fall, R1 suffered a laceration to the left ear, a hematoma on the left temple, and an acute left hip fracture. The incident was witnessed by Licensed Nurse (LN) G and another CNA, who confirmed that the mechanical lift was not defective and that the failure was due to improper use by CNA M. The facility's expectation was for two staff members to be present during such transfers to ensure resident safety.
Removal Plan
- The facility suspended CNA N.
- The facility updated R1's care plan related to ADL.
- An immediate quality assurance and performance improvement (QAPI) meeting held.
- Nursing staff education provided related to mechanical lift skills check offs and training.
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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) |
|---|---|---|---|---|
| Quaker Hill Manor | 12 mi | ★★★★★ | 20 | 0 |
| Oswego Operator, Llc | 14.1 mi | ★★★★★ | 14 | 0 |
| Galena Nursing & Rehab Center | 14.4 mi | ★★★★★ | 3 | 1 |
| Higher Call Nursing Center | 15.5 mi | ★★★★★ | 3 | 0 |
| Eastwood Manor | 16.5 mi | ★★★★★ | 0 | 0 |
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