Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Emerald Nursing & Rehab Columbus during CMS and state inspections, most recent first.
Resident room walls were observed with moisture, black/gray staining resembling mildew or mold-like substance, bubbling paint, cracks, gouges, and dirty vents in multiple rooms, including B-2, B-4, B-6, B-8, B-10, and B-12. The Tel's record review showed no reports about the wall conditions for the past 6 months, and the ADM stated the moisture had been present for a while and had not previously been brought to the ADM and Maintenance Director's attention.
A resident with type 2 DM did not receive two scheduled weekly Mounjaro injections as ordered, with no documentation in the EMAR or progress notes explaining the omissions, no entry on the incident log, and no notification to the PCP, despite facility policies requiring documentation and rationale for missed medications. In a separate incident, an LPN administering ordered long-acting and short-acting insulin via insulin pens to another resident with type 2 DM failed to prime the pens and did not hold them in place at the injection site for the required time, contrary to the facility’s clinical checklist and expectations confirmed by the DON.
Surveyors found that staff did not consistently follow EBP, hand hygiene, or glucometer disinfection policies. A resident with MRSA/MDRO history and MASD had an EBP sign and care plan requiring gown and gloves for high-contact care, yet staff performed peri care and transfers wearing only gloves, and several aides and the IP showed inconsistent understanding of which residents were on EBP and what constituted high-contact care. Multiple staff, including MAs, were observed donning and changing gloves for cares such as insulin administration and peri care without performing required hand hygiene, and one aide noted the absence of hand sanitizer in resident rooms. An LPN used the same glucometer on two residents without cleaning or disinfecting it between uses, contrary to facility policy, and later stored the device still un-sanitized in the medication cart.
The facility did not complete or display the required daily nurse staffing postings for a census of 75 residents, despite a policy requiring posting of the facility name, date, census, and total number and hours worked by nursing staff at the start of each shift. During a walk-through, surveyors observed that no daily nurse staffing information was posted, and the DON confirmed it was missing and should have been present, with only 1 nurse scheduled for days and 1 for nights. The RNC reported that daily staffing postings had not been done for about two weeks due to turnover in the scheduler position, and the new Scheduling Coordinator stated they were unaware that completing and posting daily nurse staffing information was part of their responsibilities.
Unsafe Bathroom Sink Water Temperatures: Water temperatures in 4 shared bathroom sinks measured above 120 degrees F, including readings as high as 131 degrees F. A new hot water heater had been installed without a mixing valve, and the Maintenance Director stated the water was hotter in the morning because it came fresh from the tank. The facility’s daily temperature log did not include the time of checks, identified halls rather than specific rooms, and had no weekend documentation; the Maintenance Director confirmed checks were only done Monday through Friday.
A resident with continuous O2 ordered via nasal cannula was observed with the cannula lying on the floor beside the concentrator while the resident was out of the room on two occasions. The resident had a BIMS of 15, used a walker and wheelchair, and had diagnoses including hypoxemia, OSA, and orthostatic hypotension. The DON confirmed the cannula should not have been on the floor, and the facility policy directed safe oxygen administration and proper storage of tubing when not in use.
A resident with multiple health conditions and stage 3 pressure ulcers did not receive the prescribed dressing change as ordered. An LPN was observed using a different treatment than what was ordered, applying skin prep and Medi-honey instead of the required wound cleanser and Triad paste. The LPN confirmed the mistake during an interview.
The facility failed to use required PPE and proper hand hygiene during care for two residents on Enhanced Barrier Precautions due to pressure ulcers. Staff did not wear gowns during high-contact activities, and a nurse did not change gloves or perform hand hygiene during wound care, as confirmed by the DON.
The facility did not implement its Legionella Water Management Program, failing to take measures to prevent Legionella growth in the water system. Interviews revealed that the maintenance department was not performing required actions, and the Administrator confirmed the absence of documentation for such measures, potentially affecting all 73 residents.
The facility failed to maintain a clean and safe environment, with issues such as missing baseboards, gouges, and holes in drywall, and a loose transition strip in resident rooms and corridors. These deficiencies were confirmed by the Administrator, and the Maintenance Director noted that the areas of concern had not been identified prior to the tour.
The facility failed to employ a Certified Dietary Manager and maintain sufficient staffing, leading to unsanitary conditions in the kitchen. Observations included sticky floors, food debris, and unclean equipment. Interviews revealed that routine cleaning was not completed due to staffing issues, and the Dietary Manager was not certified and often occupied with cooking duties. The Administrator confirmed the unacceptable conditions and lack of routine cleaning evidence.
The facility's kitchen environment and equipment were not maintained to prevent foodborne illness, affecting all residents. Observations revealed sticky floors, food debris, and soiled equipment. The Dietary Manager lacked certification, and routine cleaning was not completed due to staffing issues. The Administrator confirmed the unacceptable conditions.
A resident with cognitive impairment and a history of falls experienced multiple falls due to the facility's failure to consistently implement and revise fall interventions. Despite the facility's policy, interventions such as placing the bed in the lowest position, using a fall mat, and ensuring the call light was within reach were not consistently applied. Observations and interviews revealed inconsistencies in the use of fall mats and alarms, contributing to the resident's ongoing fall risk.
A resident was prescribed Cefadroxil indefinitely without proper clinical justification, despite the removal of an indwelling Foley catheter and multiple consultations with healthcare providers. The facility's Antibiotic Stewardship Policy was not effectively implemented, leading to the resident receiving unnecessary medication for an extended period.
The facility staff failed to maintain a medication error rate below 5%, with 6 errors observed out of 27 medications administered, resulting in a 22.22% error rate. Three residents received medications without food, contrary to their prescribed orders. The DON confirmed that medications should have been administered with food during breakfast.
The facility failed to serve breakfast room trays at the proper temperature, affecting two residents. Scrambled eggs were prepared at 182°F but were served at significantly lower temperatures of 78°F and 74°F. The trays were prepared and left by the Nurse's Station for 40 minutes before being distributed. A dietary aide confirmed the eggs should have been served at a minimum of 140°F.
The facility failed to provide regular bathing services for three residents, as required by their care plans and facility policy. Residents experienced multiple instances where the time between baths exceeded seven days, with gaps ranging from 8 to 29 days. Staff interviews revealed that the facility's expectation was for residents to receive baths at least once every seven days, but this was not always happening due to staffing issues. The facility administrator confirmed the deficiency.
The facility failed to provide sufficient nursing staff for bathing, affecting three residents who experienced significant gaps between baths, sometimes extending to 29 days. Staff interviews and records confirmed that residents were supposed to receive weekly baths, but this was not always happening due to staffing issues.
Resident Room Walls Found Moist, Stained, and Damaged
Penalty
Summary
Resident room walls were not kept free from moisture, black/gray staining, gouges, bubbling paint, and dirt in multiple rooms. On 5/27/26 at 11:00 AM, an observation found room B-2 with dirty vents and a small gouge in the drywall; room B-4 with an outside wall that was moist and had a grayish stain about 1 foot by 1 foot resembling mildew or a mold-like substance; room B-6 with a moist outside wall, a black/gray substance resembling mildew, and several bubbles and cracks in the paint; room B-8 with an outside wall that felt moist to touch and had a blackish/gray substance about 2 feet by 2 feet resembling mildew or a mold-like substance; room B-10 with streaks and stains going down the outside wall; and room B-12 with cracks in the drywall, streaks down the wall, and bubbling paint. A record review of the Tel's program showed no report regarding the resident walls for the past 6 months. During an environmental tour on 5/28/2026 at 1:00 PM with the Administrator and Maintenance Director, the same wall conditions were confirmed in rooms B-2, B-4, B-6, B-8, B-10, and B-12. In an interview at that time, the Administrator stated the moisture on the walls in the resident rooms had been there for a while and should have been reported by staff who see the wall daily, and also stated this was the first time the walls had been brought to the Administrator and Maintenance Director's attention.
Failure to Administer and Document Diabetes Medications per Orders and Standards
Penalty
Summary
The deficiency involves failures in medication administration and documentation for residents with type 2 diabetes. Facility policy on Medication Administration requires that medications be given in the correct dose, at the scheduled time, by the correct route, and that administration be documented in the MAR as soon as the medication is given, with a reason documented if a dose is omitted. The Medication Errors policy requires documentation of the rationale for each medication not administered. For one cognitively intact resident with type 2 diabetes, the order summary showed a standing order for a weekly subcutaneous Mounjaro injection starting in mid-November. The EMAR showed that the Mounjaro injections were not administered on two specific dates. The resident confirmed not receiving the injections on at least two occasions and expressed concern about the missed doses after a prior diabetes medication had been discontinued. There were no progress notes addressing the missed injections, no documentation of a medication error on the facility’s incident log, and no notification to the resident’s primary care provider. A second deficiency involved improper insulin administration technique using insulin pens. The facility’s clinical performance checklist for administering insulin via insulin pen requires attaching a new needle, priming the pen by dialing to 2 units and expelling insulin to remove air bubbles, and then administering the injection by inserting the needle, slowly depressing the injection knob, and holding the pen in place at the injection site for 6–10 seconds before removal. One resident with type 2 diabetes had orders for long-acting insulin in the morning and at night, and short-acting insulin on a sliding scale before meals and at bedtime based on blood glucose levels. During an observation of an LPN preparing and administering insulin to this resident, the LPN verified the ordered doses, cleaned the rubber stopper, dialed the correct units for both long-acting and short-acting insulin, and injected both doses into the resident’s upper arm. However, during this observed administration, the LPN did not prime either insulin pen before dialing up and injecting the ordered doses and did not hold either pen at the injection site for the required 6–10 seconds after depressing the plunger. The LPN later confirmed that neither pen had been primed and that the pens were not held in place after injection as required by the facility’s checklist. The DON confirmed that the resident with the missed Mounjaro injections did not receive the scheduled doses on the two identified dates, that there was no documentation in the progress notes regarding the missed injections, that the primary care provider was not notified, and that no incident or medication error report was filed for these events. The DON also confirmed that the facility’s expectation is that insulin pens be primed prior to use and held in place for at least 10 seconds after injection to ensure accurate dosing, which did not occur in the observed administration.
Failure to Follow EBP, Hand Hygiene, and Glucometer Disinfection Protocols
Penalty
Summary
Surveyors identified that the facility failed to follow its own Enhanced Barrier Precautions (EBP) and hand hygiene policies, as well as its glucometer disinfection procedures. For a resident with a history of MRSA and MDRO infection and Moisture Associated Skin Damage (MASD) on the back of the thighs, an EBP sign at the room door instructed staff to wear gown and gloves for high-contact care such as hygiene and brief changes. The resident’s comprehensive care plan also directed staff to wear gowns and gloves during high-contact care. However, during peri care, a nursing assistant wore gloves but did not don a gown, despite gowns and gloves being available in the room. The nursing assistant reported being unsure if a gown was required, and other nursing assistants demonstrated inconsistent understanding of which residents were on EBP and which activities, such as peri care and oral care, were considered high-contact. The infection preventionist later confirmed that peri care is a high-contact activity requiring gown and gloves for residents on EBP, and the resident reported that staff do not wear gowns during peri care or transfers. Surveyors also observed multiple failures in hand hygiene practices despite facility policies requiring hand hygiene before and after resident contact, and before donning and after removing gloves. Medication aides were seen putting on gloves to provide care, including insulin administration, without performing hand hygiene beforehand, and one aide changed gloves without performing hand hygiene between glove changes. Another observation showed staff transferring a resident to the toilet, performing peri care, and changing the resident’s brief without performing hand hygiene before gloving or when changing gloves. One nursing assistant confirmed there was no hand sanitizer in resident rooms and that they did not have any. Staff interviewed acknowledged that they should have performed hand hygiene before putting on gloves and when changing gloves. The administrator confirmed that no audits were being conducted on EBP or handwashing practices, while the infection preventionist stated that the facility’s expectation was hand hygiene before and after all resident care and with all glove use. In addition, the facility did not follow its policies for cleaning and disinfecting blood glucose monitors between residents. The policies required cleaning and disinfecting the glucometer after each use, including using a disinfectant wipe and allowing appropriate drying time, to prevent transmission of bloodborne diseases. During medication administration, an LPN obtained a blood glucose level for one resident, then placed the glucometer on the medication cart without cleaning or disinfecting it. The same un-sanitized glucometer was then used to obtain a blood glucose level for another resident, again without any cleaning or disinfection between uses, and was later stored in the medication cart drawer still un-sanitized. The LPN confirmed that the glucometer had not been cleaned or disinfected and acknowledged it should have been, and the DON stated that the facility’s expectation was that glucometers are cleaned and disinfected between each resident use.
Failure to Complete and Post Required Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the required Daily Nurse Staff Posting was completed and displayed as specified in its policy, which required posting of the facility name, current date, current census, and total number and actual hours worked for nursing staff at the beginning of each shift and maintaining these postings for 18 months. During an observation on 4/28/2026 at 9:37 AM, surveyors found no daily nursing staff posting anywhere in the facility. In an interview at the same time, the DON confirmed that the daily nurse posting was not posted and acknowledged it should have been. The DON further confirmed that the facility census was 75, with 1 nurse scheduled for the day shift and 1 nurse scheduled for the night shift. In a subsequent interview on 4/28/2026 at 12:48 PM, the Regional Nurse Consultant stated that the facility had not performed the required daily staff posting for the previous two weeks due to turnover in the scheduler position. On 4/29/2026 at 8:10 AM, the Scheduling Coordinator reported having started in the role on 4/8/2026 and being unaware that the daily nurse staffing information was required to be completed or posted. No additional resident-specific medical histories or conditions were described in the report beyond the facility census of 75 residents.
Unsafe Bathroom Sink Water Temperatures
Penalty
Summary
The facility failed to provide comfortable and safe water temperatures in 4 shared bathroom sinks down East Hall. During observation with the Maintenance Director, water temperatures taken from the bathroom sinks measured above 120 degrees F, including 126.1 degrees F, 126.9 degrees F, 131 degrees F, and 126 degrees F. The affected bathrooms served residents in rooms 1, 3, 5, and 7, and the facility census was 85. The Maintenance Director stated the facility had installed a new hot water heater about 6 months earlier to supply hot water to both East and North halls, but a mixing valve had not been placed on the heater at the time of installation. The Maintenance Director explained that the water was hotter in the morning because it had not been used yet and was coming fresh from the hot water tank, and that lowering the temperature would make it not warm enough later in the day. The director confirmed that bathroom sink water should not be hotter than 120 degrees F. The facility’s daily hot water temperature log did not include the time temperatures were taken, and the record review showed temperatures ranging from 101.3 degrees F to 116.6 degrees F, with entries identifying halls rather than specific resident room numbers. The log also had no documentation for Saturdays or Sundays, and the Maintenance Director confirmed that water temperature checks were only completed Monday through Friday.
Oxygen Cannula Left on Floor
Penalty
Summary
Provide and implement an infection prevention and control program was cited after surveyors observed Resident 51's nasal cannula on the floor beside the oxygen concentrator on two separate occasions while the resident was out of the room. Resident 51 was admitted to the facility on 7/31/25 and had a BIMS score of 15, indicating cognitive intactness. The resident used a walker and wheelchair, required varying levels of assistance with ADLs, and had continuous oxygen ordered at 2 liters via nasal cannula to keep saturations above 90% at all times for shortness of breath. Record review showed the resident also had diagnoses of obstructive sleep apnea, hypoxemia, and orthostatic hypotension, and the care plan addressed oxygen therapy and ineffective gas exchange. The physician's orders directed continuous oxygen use and to change the oxygen cannula and tubing as needed for patency. The facility's oxygen administration policy stated that oxygen cannula and tubing used PRN should be kept in a plastic bag when not in use. During interview, the DON confirmed the oxygen tubing cannula should not be on the floor.
Failure to Follow Dressing Change Orders for Pressure Ulcer
Penalty
Summary
The facility failed to adhere to a practitioner's orders for a dressing change for a resident with pressure ulcers. The resident, who was admitted with multiple health conditions including anemia, high blood pressure, diabetes, anxiety, manic depression, and chronic obstructive pulmonary disease, was assessed to have short- and long-term memory loss, severely impaired decision-making skills, and required total assistance with daily activities. The resident had two unhealed stage 3 pressure ulcers upon admission, and the care plan indicated skin integrity issues due to being bedridden for 28 days prior to admission. On a specific date, an LPN was observed performing wound care on the resident's coccyx pressure ulcer. The LPN did not follow the prescribed order, which required cleansing with a wound cleanser and applying Triad paste twice daily. Instead, the LPN used a skin prep and Medi-honey, which was not in accordance with the practitioner's orders. The LPN later confirmed the error during an interview, acknowledging the incorrect dressing change procedure.
Inadequate PPE Use and Hand Hygiene in Resident Care
Penalty
Summary
The facility failed to adhere to its infection prevention and control program by not utilizing the required Personal Protective Equipment (PPE) during direct care activities for two residents on Enhanced Barrier Precautions (EBP). Specifically, staff members did not wear gowns when performing high-contact care activities for Residents 3 and 4, who were on EBP due to pressure ulcers. During an observation, Nurse Aide (NA)-D and Medication Aide (MA)-E did not wear gowns while transferring Resident 3 from a wheelchair to a bed and changing bed linens. Similarly, NA-M did not wear a gown while assisting Resident 4 with dressing, transferring, and toileting. Additionally, the facility did not follow proper hand hygiene and gloving techniques during wound care for Resident 3. Registered Nurse (RN)-F failed to change gloves after removing a dressing and applying barrier cream to Resident 3's pressure ulcer. RN-F also did not perform hand hygiene before assisting with other care activities. These actions were confirmed by the Director of Nursing (DON), who acknowledged that the staff should have adhered to the facility's policies on PPE use and hand hygiene to prevent potential cross-contamination.
Failure to Implement Legionella Water Management Program
Penalty
Summary
The facility failed to implement its Legionella Water Management Program, which is crucial for preventing water-borne illnesses such as Legionnaire's disease. The policy, last revised in January 2024, outlined the formation of an interdisciplinary water management team and detailed procedures to identify and mitigate areas in the water system that could foster the growth of Legionella bacteria. However, interviews with the Maintenance Director and the Infection Preventionist revealed that no measures were being taken to prevent the growth of Legionella, and the maintenance department, which was responsible for these measures, was not performing them. The Administrator confirmed that there was no documentation of any actions taken to prevent Legionella growth, indicating a complete lack of implementation of the water management policy. This deficiency had the potential to affect all 73 residents of the facility, as the policy was designed to reduce the risk of Legionnaire's disease by monitoring and controlling the water system effectively. The absence of documentation and action suggests a significant oversight in the facility's infection prevention and control program.
Environmental Deficiencies in Resident Rooms and Corridors
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, as evidenced by the observations made during an environmental tour. The tour revealed several deficiencies in the cleanliness and condition of the facility's walls, floors, and baseboards in five resident rooms and the Northwest corridor. Specific issues included missing baseboards, scrapes, gouges, and holes in the drywall in various rooms, as well as a loose transition stop strip with exposed and discolored flooring. These deficiencies were confirmed by the facility's Administrator during the tour. The Maintenance Director (MD) indicated that a patch panel had been affixed to a wall in one of the rooms due to the wall caving in. However, the MD also reported that the areas of concern had not been identified prior to the environmental tour, despite the existence of a Maintenance Request Log kept at the Nurse's Station. This suggests a lack of proactive maintenance and monitoring of the facility's environment, leading to the observed deficiencies.
Deficiency in Kitchen Cleanliness and Staffing
Penalty
Summary
The facility failed to employ a Certified Dietary Manager (CDM) and maintain sufficient staffing to ensure the cleanliness of the kitchen environment, food preparation equipment, and storage equipment, potentially affecting all 73 residents who consumed food prepared by the facility. The job description for the Manager of Dining Services outlined responsibilities including managing the dietary department, ensuring food was prepared and served according to regulations, and maintaining cleanliness and safety standards. However, during an inspection, numerous deficiencies were observed in the kitchen's cleanliness and maintenance. During a tour of the primary kitchen, surveyors noted several unsanitary conditions, including a sticky floor, food debris in grout, and a thick black substance coating various surfaces. The fire suppression system and oven doors were covered in sticky and burnt substances, respectively. Additionally, the food steamer was leaking water, and the walls were coated in a brown sticky substance. Cooking pots were covered in black carbon buildup, and the air return covers had chipping paint and rust. The dry food storage area and walk-in freezer had boxes of food stored directly on the floor, and food service carts were covered in food debris. Interviews with the Dietary Manager and staff revealed that routine cleaning was not being completed due to staffing issues, and the Dietary Manager was not certified and often occupied with cooking duties. The facility Administrator confirmed the unacceptable conditions and acknowledged the lack of evidence for routine cleaning. The Administrator also confirmed that the Dietary Manager had not completed the required training and was frequently involved in cooking, which hindered the maintenance of the kitchen environment and equipment.
Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen environment, food storage, and preparation equipment in a manner that prevents the potential for foodborne illness, affecting all residents who consumed food prepared by the facility. During an initial tour of the primary kitchen, several deficiencies were observed, including a sticky floor, food debris in grout, and a thick black substance coating the floor beneath various kitchen equipment. The fire suppression system and oven doors were coated with sticky and burnt substances, respectively. Additionally, the food steamer was leaking water into a pan, which was overflowing and cloudy, and the walls adjacent to the oven were covered in a brown sticky substance. Further observations revealed that cooking pots were coated with black carbon buildup, air return covers had chipping paint and rust, and bins of flour and sugar were contaminated by drippings from the food steamer. The reach-in refrigerators and freezers had handprints, smears, and frozen substances, with food boxes stored directly on the floor in both dry and walk-in storage areas. Food service carts and equipment wheels were heavily soiled, and the secondary kitchen exhibited similar issues, including a sticky floor, soiled ice machine, and lime buildup in the dishwashing room. Interviews with the Dietary Manager (DM) and Dietary Staff (DS) revealed that routine cleaning was not being completed due to staffing concerns, and the DM lacked current certification. The facility Administrator confirmed the unacceptable condition of the kitchen and acknowledged that the DM was frequently cooking, which hindered the maintenance of the kitchen environment and equipment. The facility had no evidence of routine cleaning being conducted.
Failure to Implement and Revise Fall Interventions
Penalty
Summary
The facility failed to implement and revise fall interventions for a resident, leading to multiple falls. The resident, who had a history of adult failure to thrive, previous heart attack, and pain, was assessed as having moderately impaired cognition and displayed various behaviors such as verbal and physical aggression, self-harm, and rejection of care. The resident was dependent on assistance for dressing, bed mobility, and transfers, and had experienced a fall without injury since the last assessment. The facility's fall management policy required assessing fall risk at admission, quarterly, or after a fall, and implementing individualized interventions. However, the facility did not consistently follow this policy. The resident experienced several falls, with investigations revealing that interventions such as placing the bed in the lowest position, using a fall mat, and ensuring the call light was within reach were not consistently implemented. Additionally, there was a lack of documentation and communication regarding the removal of the fall mat and the failure to develop new interventions after subsequent falls. Observations and interviews indicated that the resident's call light was often not within reach, and the use of fall mats and alarms was inconsistent. The Director of Nursing confirmed that new interventions were not developed after certain falls and that the fall mat was removed without proper documentation. This lack of consistent implementation and revision of fall interventions contributed to the ongoing risk of falls for the resident.
Failure to Address Unnecessary Long-term Antibiotic Use
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically concerning the long-term use of the antibiotic Cefadroxil. The resident, who had an indwelling Foley catheter, was prescribed Cefadroxil indefinitely by a urologist after cloudy urine was observed. However, there was no urinalysis conducted to support the clinical use of the antibiotic. Despite the removal of the catheter and multiple consultations with both the primary physician and the urologist, the continued use of Cefadroxil was not adequately addressed. The consultant pharmacist repeatedly recommended reviewing the necessity of the antibiotic, but the primary physician deferred the decision to the urologist, who also failed to provide a clear directive. The resident's medical record showed that the Cefadroxil was prescribed without a specified duration, and the facility's Antibiotic Stewardship Policy was not effectively implemented. The policy required tracking antibiotic use, ensuring pharmacy review, and monitoring for adverse reactions, but these measures were not sufficiently followed. The resident continued to receive Cefadroxil without a stop date, and the facility did not receive any information regarding a pending urine culture that could have informed the necessity of the antibiotic. This oversight led to the resident receiving unnecessary medication for an extended period without proper clinical justification.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility staff failed to maintain a medication error rate below 5%, as required by their policy. During observations, 27 medications were administered, resulting in 6 errors, which equates to an error rate of 22.22%. These errors involved three residents, who were not given their medications in accordance with the prescriber's orders. Specifically, the medications were not administered with food as required, which is a deviation from the prescribed method of administration. Resident 5 was prescribed Metformin to be taken with food, but the medication was administered without offering food. Similarly, Resident 19 was given Glimepiride, Metformin, Potassium Chloride, and Aspirin without food or a full glass of water, contrary to the orders. Resident 68 was prescribed Meloxicam to be taken with food, but it was administered without food. The Director of Nursing confirmed that these medications should have been administered with food during the breakfast meal, indicating a lapse in following the prescribed medication administration protocol.
Improper Temperature of Breakfast Trays
Penalty
Summary
The facility failed to ensure that room trays were palatable and served at the proper temperature, affecting two residents out of four who received a breakfast room tray. The facility's Beginning Food Cooking Temperatures log indicated that all hot food should be served at a minimum of 140 degrees Fahrenheit. However, on the morning of July 15, 2024, scrambled eggs were prepared with an initial temperature of 182 degrees Fahrenheit but were later served at significantly lower temperatures. Observations revealed that a serving cart with breakfast trays was positioned next to the Nurse's Station at 8:10 AM, and the trays were not distributed until 8:50 AM. When the trays were finally delivered, the scrambled eggs on Resident 34's tray were measured at 78 degrees Fahrenheit, and Resident 66's scrambled eggs were at 74 degrees Fahrenheit. An interview with a dietary aide confirmed that the scrambled eggs should have been served at a minimum of 140 degrees Fahrenheit, and the trays had been prepared between 7:30 AM and 7:45 AM before being placed by the Nurse's Station for distribution.
Failure to Provide Regular Bathing Services
Penalty
Summary
The facility failed to provide regular bathing services for three residents, as required by their care plans and facility policy. Resident 1, who had severe cognitive impairment and required total assistance with bathing, experienced multiple instances where the time between baths exceeded seven days, with gaps ranging from 8 to 29 days. Resident 4, who was cognitively intact but required moderate assistance with bathing, also had several instances where the time between baths exceeded seven days, with gaps ranging from 14 to 21 days. Resident 5, who had severe cognitive impairment and required assistance with bathing, experienced similar issues, with gaps between baths ranging from 10 to 21 days. These deficiencies were confirmed through record reviews and interviews with staff and residents. Interviews with various staff members, including LPNs, Medication Aides, and Nursing Assistants, revealed that the facility's expectation was for residents to receive baths at least once every seven days. However, this was not always happening due to staffing issues. A confidential resident interview also revealed that the resident had gone three weeks without a bath in February and had requested to have two baths weekly. The facility administrator confirmed that residents were expected to receive weekly baths, and acknowledged that Residents 1, 4, and 5 were not receiving baths as scheduled.
Failure to Provide Sufficient Nursing Staff for Bathing
Penalty
Summary
The facility failed to provide sufficient nursing staff for the provision of bathing for three residents, which had the potential to affect all residents. During a confidential interview, a resident revealed not receiving baths on a regular schedule, going three weeks without a bath in February. The resident had severe cognitive impairment and required total assistance with bathing. The review of the resident's Minimum Data Set (MDS) and care plan confirmed the need for regular bathing assistance, but documentation showed multiple instances where the time between baths exceeded seven days, sometimes extending to 29 days apart. Similar deficiencies were found for two other residents, one with cerebral palsy and another with severe cognitive impairment, both requiring assistance with bathing and experiencing significant gaps between baths, ranging from 10 to 21 days apart. The facility's nursing assignment records from November 1, 2023, to April 30, 2024, revealed numerous dates without a bath aide scheduled and multiple instances where two or more staff members did not report to work. Interviews with various staff members confirmed that residents were supposed to receive baths at least once every seven days, but this was not always happening due to staffing issues. The administrator confirmed that the expectation was for residents to receive weekly baths and acknowledged that the residents in question were not getting their baths completed weekly. The bath aide was often reassigned to other duties when there were staff call-ins, further contributing to the deficiency in providing regular bathing assistance.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 61 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Columbus
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brookestone Acres | 0.7 mi | ★★★★★ | 18 | 0 |
| St. Joseph's Villa, Inc. | 18.3 mi | ★★★★★ | 20 | 0 |
| Genoa Community Hospital/ltc | 18.3 mi | ★★★★★ | 0 | 0 |
| Brookestone Of David City | 19 mi | ★★★★★ | 0 | 0 |
| Good Samaritan Society - Osceola | 20.1 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Emerald Nursing & Rehab Columbus.
100% money-back within 48 hours.
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.