Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Capital City Gardens Rehabilitation And Nursing Ce during CMS and state inspections, most recent first.
Surveyors identified multiple environmental deficiencies, including severely damaged walls and floorboards around a nursing station, exposed drywall and hot water pipes, missing privacy curtains at toilets, and shower fixtures held together with disposable gloves in two shower rooms. Additional findings included soiled grout, missing tiles exposing bare wall, and an unsecured lightbulb hanging from exposed wiring above a shower. A maintenance director acknowledged being unaware of some issues and confirmed the disrepair, while a regional maintenance leader verified that a loose handrail and crumbling concrete at a handicapped ramp and upper walkway were known problems, even though residents rely on the rail for support.
Unsafe food preparation and storage practices were observed in the kitchen. A dietary aide was preparing breakfast trays without a hairnet, and multiple food items in the ready refrigerator and walk-in refrigerator were found opened and/or undated, including applesauce, juice, pudding, salads, soup, and cheeses. Facility staff verified the observations, and the facility policy required refrigerated and frozen foods to be covered, labeled, and dated.
Failure to follow EBP and secure an IV bag: A resident with an IV antibiotic order and EBP for MDRO-related care had a Ceftazime IV bag lying on the floor while still connected to the IV line. In addition, a CNA provided incontinence care without wearing a gown, despite posted EBP instructions requiring gown and glove use for high-contact care such as transferring and toileting/brief changes.
Unnecessary antipsychotic use without CMS-supported indication. A resident with moderate cognitive impairment and multiple chronic diagnoses was receiving Lurasidone 20 mg daily despite a psychiatric note stating the medication lacked a CMS-supported indication and was without an appropriate diagnosis per CMS guidelines. An RN confirmed the resident was still on the medication and acknowledged it was not recognized as appropriate per CMS guidelines, while citing a mood disorder documented by another provider as the basis for use.
Failure to Investigate Allegation of Verbal Abuse: A resident with necrotic feet and intact cognition reported that staff made hurtful, disrespectful comments about her odor and condition, including a CNA telling her she stinks during a shower. The resident’s mother raised the concern with the Administrator during a care conference, but the Administrator did not investigate because he did not recognize it as verbal abuse. Another resident also reported hearing staff speak disrespectfully to the resident on several occasions. The facility policy required abuse allegations to be promptly reported and thoroughly investigated.
A resident with paraplegia, neurogenic bladder and bowel, heart failure, anemia, and a stage 4 PU present on admission developed three new wounds and a blister on the left foot and lower leg. The facility faxed a dermatology referral and called the office, but the appointment was not scheduled; an LPN later confirmed there was no documented follow-up call and the resident still had no dermatology appointment.
Inadequate Water Management Plan. The facility's Waterborne Pathogens Plan listed hot water temperatures of 105 F to 120 F, did not specify when or where temperature checks would occur, did not include a hot water storage range, and did not include a flushing schedule for low-flow or infrequently used areas and fixtures. The Administrator and Maintenance Director confirmed the concerns, and the deficiency was cited under a complaint investigation.
The facility failed to maintain appropriate room temperatures, affecting three residents, with temperatures recorded below the acceptable range due to HVAC issues. Additionally, a resident's room had a leaking sink faucet due to scaling buildup, which was not addressed despite the resident's complaints. These deficiencies highlight the facility's failure to provide a comfortable and homelike environment as per their policy.
The facility failed to provide PPE in the laundry room for handling infectious materials, as confirmed by staff interviews. Additionally, a resident on Enhanced Barrier Precautions due to a hemodialysis catheter did not have the required signage on their room, as confirmed by the DON. These deficiencies indicate lapses in the facility's infection prevention and control program.
A resident with a complex medical history felt coerced into participating in a substance abuse program at a facility under the threat of discharge. Despite signing an agreement while hospitalized, the resident did not recall being informed about the program specifics. The facility required mandatory participation in the program, contradicting their agreement with an outpatient service provider, and threatened discharge for non-compliance.
The facility failed to ensure accurate PASARR documentation for three residents, as their current diagnoses were not reflected in the documents. This included omissions of conditions such as bipolar disorder, major depressive disorder, and insomnia, despite these being present in the residents' medical records. The deficiency was confirmed by the social services director, highlighting a lapse in the facility's coordination with the PASARR program.
The facility failed to notify the state mental health agency of significant mental health changes for three residents, affecting their PASARR documentation. One resident had multiple mental health diagnoses not updated, another had diagnoses like bipolar disorder and anxiety disorder missing from documentation, and a third had an inaccurate PASARR screening missing insomnia. Social Services confirmed the inaccuracies, and the facility's policy requiring coordination with the PASARR program was not followed.
The facility failed to obtain weekly weights for two residents as per physician orders, affecting nutritional monitoring. One resident, with complex medical conditions, had only one weight recorded despite orders for weekly checks. Another resident experienced significant weight fluctuations, but the facility did not continue weekly weights as recommended. The facility's policy required weekly weights, but this was not followed, as confirmed by staff interviews.
A resident with chronic respiratory conditions was readmitted to the facility without necessary BiPap orders, despite needing it nightly to prevent life-threatening risks. The omission of these orders was confirmed by the DON and a CNP, indicating a failure to meet the resident's respiratory care needs.
A facility failed to maintain ongoing communication with a dialysis vendor for a resident with chronic kidney disease and end-stage renal disease. The resident had regular dialysis appointments, but post-dialysis forms were incomplete, and staff did not consistently follow up with the dialysis center. Interviews revealed that communication needed improvement, and the facility's policy required ongoing communication about treatment details.
A facility failed to provide parameters for as-needed pain medication for a resident with a complex medical history. The resident's medication orders included acetaminophen, naproxen, and oxycodone, but lacked specific guidelines for administration based on pain levels. Interviews revealed that the facility allowed residents to choose their medication, leading to inconsistent administration practices.
A resident with a history of cerebral infarction and other conditions was found with a medicine cup containing tablets and capsules on the overbed table without a documented assessment for self-medication or a physician's order. The LPN confirmed the medications were left because the resident preferred to take them after breakfast, but did not realize they had not been taken. The DON confirmed that nurses are expected to observe medication administration according to professional standards.
The facility failed to conduct thorough investigations and documentations of allegations of abuse and misappropriation involving three residents. A resident reported a CNA pushed him, another resident reported inappropriate touching by a fellow resident, and a third resident reported a missing earring. In each case, the facility's investigation was incomplete, lacking detailed statements from the residents and relying on identical staff statements that did not recall specific events or interactions.
A facility failed to follow infection control procedures during a dressing change for a resident with multiple health conditions, as an LPN did not wear a gown or wash hands between glove changes. Additionally, improper handling of soiled laundry was observed, with staff throwing laundry down a stairwell and leaving it unbagged, contrary to infection control policies.
A plumbing failure in the B hallway shower room led to severe flooding and unsanitary conditions, affecting residents and staff. The issue persisted over several days, with brown, foul-smelling water reported in hallways and rooms. Despite attempts to manage the situation, structural issues remained unaddressed, violating the facility's maintenance policy.
A resident in a LTC facility sustained severe burns after staff failed to promptly implement fire procedures during a fire in her room. Despite the fire alarm and sprinkler activation, staff delayed in rescuing the resident and extinguishing the fire. The resident, who had a history of mental health issues and was a supervised smoker, intentionally started the fire. Staff inaction included walking past a fire extinguisher without using it and not evacuating other residents, leading to neglect and risk of serious harm.
A resident who required supervision while smoking was found with smoking materials in her room, leading to a fire that caused severe burns. Despite the facility's policy requiring smoking materials to be stored by staff, the resident accessed a lighter and cigarettes, igniting her mattress. The fire department concluded the fire was accidental, caused by smoking materials near high-concentration oxygen. Interviews revealed the facility did not consistently enforce its smoking policy, allowing residents to keep smoking materials in their rooms.
A resident suffered burns during a fire in her room due to the facility's failure to implement fire protocol. Staff did not use a fire extinguisher or evacuate residents promptly, as observed in video footage. The facility delayed reporting the incident to authorities.
A facility failed to manage resources effectively, resulting in a fire incident where a resident, who was supposed to have smoking materials stored by the facility, ignited her bed, causing severe burns. The facility did not report the incident timely, and the investigation was inadequate, revealing a delay in staff response and failure to follow fire safety procedures. The facility's smoking policy was not enforced, and emergency preparedness training was insufficient, placing multiple residents at risk.
A resident at high risk for falls did not have required interventions in place, such as a bed in the lowest position, non-skid footwear, and a reachable call light. An LPN confirmed these lapses, noting the resident's preferences and meal-related adjustments. The facility's fall prevention policy was not followed.
The facility failed to maintain proper infection control during medication administration for a resident with respiratory failure, as a nurse handled oral medications with bare hands. Additionally, the facility did not implement enhanced barrier precautions for a resident with an open coccyx wound, as nurses did not wear gowns during dressing changes, contrary to facility policy.
The facility was found to be in disrepair and unclean, affecting all 87 residents. Observations revealed missing transition strips, dirty and chipped door frames, peeling wallpaper, rusting vents, and splatter marks on walls. The therapy gym had a chipping door with a sharp edge, and the C and B hallways had dirty floors and walls. The downstairs counseling space had exposed brick, and the staff lounge was closed due to a water leak and mold-like substance. Employees faced slip, trip, and fall hazards from leaking pipes and potential health hazards from untreated mold. A policy for maintaining a safe and sanitary environment was not provided.
A resident, dependent on staff for personal hygiene due to medical conditions, was not assisted with shaving her face because of a lack of supplies. Despite having intact cognition and not refusing care, the resident had not been shaved since admission, leading to embarrassment. The DON confirmed the presence of facial hair but claimed the resident was not bothered. Facility policy required staff to assist with grooming, which was not followed.
A resident with a seizure disorder did not receive their prescribed valproic acid solution from 02/14/24 through 03/13/24 due to a transcription error by the admitting nurse. The resident was readmitted to the hospital with seizure activity, and the error was confirmed by the facility's Director of Nursing.
Environmental Disrepair and Safety Hazards in Resident Care Areas and Entrances
Penalty
Summary
The facility failed to ensure a safe, comfortable, and homelike environment for residents, staff, and the public, with the potential to affect all 91 residents. On one hall, surveyors observed that the walls, paneling, and floorboards around the C hall nursing station were severely damaged and in significant disrepair, including exposed drywall and missing floorboards. In the B hall shower room, there were exposed hot water shutoff pipes visible through missing drywall or door covering, ripped or missing drywall immediately outside the shower, no privacy curtain around the toilet, plumbing fixtures at the shower head held together by disposable gloves, and soiled grout with approximately one foot of missing tile exposing bare wall at the bottom of the shower. The Maintenance Director confirmed that the hot water pipes should be covered, was unaware of the gloves holding the shower head together, and acknowledged the other conditions, stating they would not want their own home to appear as the shower room did. Further observations showed similar issues in the C hall shower room, including no privacy curtain around the toilet, a shower head held together by disposable gloves, and a lightbulb not securely installed or covered, hanging from exposed electrical wiring directly above the shower. During a concurrent interview, the Maintenance Director stated that nobody informs them about such issues and verified the disrepair, including the exposed lightbulb and wiring. The Maintenance Director also confirmed that the walls around the C hall nurse's station were in significant disrepair. Outside the facility, surveyors observed a loose railing at the bottom of the handicapped ramp entrance/exit that moved easily with regular force, as well as crumbling and broken concrete below the railing on the upper-level walkway near the main entrance steps. The Regional President of Maintenance verified the loose railing, acknowledged that residents use it for assistance, and confirmed awareness of the crumbling concrete. These findings were investigated under Complaint Numbers 2979015 and 2784905.
Unsafe Food Storage and Preparation Practices
Penalty
Summary
The facility failed to ensure food was prepared and stored in a safe and sanitary manner. During observation of the kitchen, Dietary Aide #217 was preparing breakfast trays with waist-length braids and no hairnet on, and Dietary [NAME] #215 verified the observation at the time. In the ready refrigerator, one cup of applesauce, one eight-ounce glass of orange juice, one clear container of pudding, and ten salads in brown bowls were found undated, and Dietary Aide #217 verified the undated items. In the walk-in refrigerator near the dry food storage area, one bowl of chicken noodle soup, one bag of mozzarella cheese, one bag of salad, and one bag of cheddar cheese were found opened and undated, and Dietary [NAME] #216 verified these findings. Review of the facility policy dated July 2014 stated that all foods stored in the refrigerator or freezer will be covered, labeled, and dated with a use-by date.
Failure to Follow Enhanced Barrier Precautions and Secure IV Bag
Penalty
Summary
The facility failed to follow enhanced barrier precautions for a resident with an IV antibiotic order and an order for enhanced barrier precautions related to indwelling medical devices, wounds, and/or infection with a multidrug resistant organism. Resident #3 was admitted with abscess of the liver and diagnoses including vancomycin resistance and bacterial infections involving enterococcus, proteus mirabilis, and pseudomonas. The resident also had a BIMS score of 9, indicating moderate cognitive impairment. Observation showed an IV bag labeled Ceftazime lying on the floor beneath the resident’s bed while still connected to the resident’s peripheral IV in the right arm, and CNA #621 confirmed the bag should not be on the floor while connected. The facility also failed to ensure staff followed the gown requirement for enhanced barrier precautions during high-contact care. During observation, CNA #621 was providing incontinence care to Resident #3 without wearing a gown, even though the posted enhanced barrier precautions instructions required gloves and a gown for activities such as transferring and toileting or incontinence care. CNA #621 confirmed they were not wearing a gown and stated they had entered the room to transfer the resident and then found the resident incontinent and needing brief change and incontinence care.
Unnecessary Antipsychotic Use Without CMS-Supported Indication
Penalty
Summary
The facility failed to ensure antipsychotic medications were used for an indicated diagnosis for one resident reviewed for unnecessary medications. Resident #73 was admitted with diagnoses including intervertebral disc disorder with radiculopathy in the lumbar region, COPD, Type 2 diabetes mellitus, alcoholic cirrhosis of the liver with ascites, generalized muscle weakness, and need for assistance with personal care. The resident also had a BIMS score of 12, indicating moderate cognitive impairment. Medication review showed an order for Lurasidone 20 mg daily, started on 11/12/25, and the resident was still receiving it at the time of the survey. A psychiatric note dated 03/24/26 stated that gradual dose reduction of Lurasidone was discussed, but the patient declined, and that the medication lacked a CMS-supported indication. The same note stated the patient was on Lurasidone 20 mg without an appropriate diagnosis according to CMS guidelines and that symptoms would be monitored with a GDR attempted when clinically stable. During interview, Regional RN #212 confirmed the resident remained on Lurasidone 20 mg daily and stated the medication was not indicated or recognized as appropriate per CMS guidelines, although they believed a mood disorder documented by another provider was an acceptable indication. The facility policy stated residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective.
Failure to Investigate Allegation of Verbal Abuse
Penalty
Summary
The facility failed to investigate an allegation of verbal abuse involving one resident who was admitted with diagnoses including frostbite with tissue necrosis of unspecified sites, vascular Ehlers-Danlos syndrome, chronic viral hepatitis, and major depressive disorder. The resident had a BIMS score of 15, indicating no cognitive impairment. During review of the resident’s record, the care conference documentation did not mention staff making disrespectful comments about the resident’s feet or any smell-related concerns, despite later statements that such comments had been made. The resident stated that staff had not been speaking respectfully and reported that a CNA told her she stinks while assisting with a shower and said her necrotic feet smell. The resident’s mother stated she raised these concerns with the Administrator during a care conference, and the Administrator confirmed the issue was brought to his attention but was not investigated because he did not recognize it as an allegation of verbal abuse. Another resident reported hearing staff speak disrespectfully to the resident on several occasions, including telling her that she stinks. The facility policy required all reports of abuse, mistreatment, and related allegations to be promptly reported and thoroughly investigated by facility management.
Delayed Dermatology Follow-Up for Resident With New Wounds
Penalty
Summary
The facility failed to ensure a follow-up dermatology appointment was scheduled in a timely manner for a resident with multiple complex medical conditions, including paraplegia, neurogenic bowel and bladder, heart failure, anemia, and a stage four pressure ulcer present on admission. The resident also developed three new wounds to the left lateral foot, left posterior lower calf, and a fluid-filled blister to the bottom of the left foot. An ankle-brachial index test was normal, and a referral was made to an outside dermatology office for further evaluation. A progress note documented that an order was received for the facility to schedule the dermatology appointment, and another note stated the facility called the dermatology office and was told the office was about a week behind on referrals and could not yet schedule the appointment. During interview, the LPN unit manager stated she faxed the referral and called the dermatology office, was told they would call back, and then called again about a month later when the office still could not schedule. There was no progress note documenting a follow-up call to the dermatology office, and the resident still did not have a dermatology appointment.
Inadequate Water Management Plan
Penalty
Summary
Provide and implement an infection prevention and control program. Based on review of the facility's Waterborne Pathogens Plan, staff interview, and review of the CDC Legionella Control Toolkit, the facility failed to have an adequate water management plan. The Waterborne Pathogens Plan dated revised 01/07/24 listed hot water temperature ranges of 105 degrees Fahrenheit (F) to 120 degrees F, which was not a preventative range for Legionella growth. The plan also did not specify a timeframe for temperature checks, control points for where temperatures would be taken, a temperature range for hot water storage, or a recommended flushing schedule for low-water flow or infrequently used areas and fixtures. Interview with the Administrator and Maintenance Director #120 confirmed these concerns with the facility's Waterborne Pathogens Plan. The deficiency was identified under Complaint Number 2734119 and had the potential to affect all 93 residents in the facility.
Facility Fails to Maintain Appropriate Room Temperatures and Address Maintenance Issues
Penalty
Summary
The facility failed to maintain appropriate air temperatures in resident rooms, affecting three residents. One resident, who was cognitively intact, was observed under multiple blankets due to cold temperatures in her room, which was recorded at 66 degrees Fahrenheit. The resident reported that the room was consistently cold, and maintenance staff confirmed the issue was due to air pockets in the HVAC system. Another resident also experienced cold room temperatures, recorded at 68 degrees Fahrenheit, and reported the issue had persisted for about a week. The maintenance director confirmed the temperature was outside the acceptable range and attributed it to the same HVAC issue. A third resident, who was also cognitively intact, reported that their room had been cold since admission, with temperatures fluctuating between 69 and 70 degrees Fahrenheit. The maintenance director confirmed the room temperature was below the acceptable range of 71 to 81 degrees Fahrenheit. The facility's policy on providing a homelike environment specifies maintaining comfortable and safe temperatures within this range. Additionally, the facility failed to address a maintenance issue in another resident's room, where a sink faucet was leaking due to a buildup of scaling. The resident, who was cognitively intact and had a diagnosis of anxiety, reported the issue and found the noise annoying. Despite notifying staff, the maintenance director was unaware of the problem and no request had been made to fix the sink. This oversight further contributed to the facility's failure to provide a comfortable and homelike environment as per their policy.
Infection Control Deficiencies in PPE and Isolation Procedures
Penalty
Summary
The facility was found to have deficiencies in its infection prevention and control program. During an observation of the laundry room, it was noted that there was no personal protective equipment (PPE) available for handling infectious materials. This was confirmed through interviews with the Housekeeping Supervisor and a Laundry Aide. Additionally, a Corporate Nurse revealed that there were residents on transmission-based precautions due to infections, yet the facility's policy from August 2014, which mandates the use of gloves for contact with potentially hazardous materials, was not being followed. Furthermore, the facility failed to implement proper isolation procedures for a resident with a hemodialysis catheter, who was on Enhanced Barrier Precautions. Observations showed that there was no signage on or outside the resident's room to indicate these precautions, which was confirmed by the Director of Nursing. The facility's policy from April 2024 requires signage to ensure staff awareness of hand hygiene and gown/glove use when Enhanced Barrier Precautions are in place, but this was not adhered to in the case of the resident.
Resident's Right to Refuse Treatment Violated
Penalty
Summary
The facility failed to honor a resident's right to refuse treatment without the threat of discharge, affecting one resident reviewed for dignity and rights. The resident, who was cognitively intact, had a complex medical history including osteomyelitis, asthma, and substance abuse. She signed a Substance Use Disorder Program agreement while hospitalized, agreeing to participate in the facility's Stepping Stones program. However, upon admission, she felt coerced into participating in the program under the threat of discharge, despite not recalling being informed about the program specifics during her hospital stay. Interviews with the resident revealed she felt forced to participate in the Stepping Stones program, which included counseling, drug testing, and supervised visits, under the threat of being discharged. She expressed that she did not want to participate in these activities and would not have chosen the facility had she known participation was mandatory. The facility's administrator and counselor confirmed that residents are required to sign a contract agreeing to the program before admission, and refusal to participate would lead to discharge planning. The facility's agreement with Stepping Stones Outpatient Services, LLC, stated that residents are not obligated to use the services offered by the provider. However, the facility's practice contradicted this agreement, as refusal to participate in the program led to discharge planning. The facility's policy required mandatory participation in the program, and refusal resulted in immediate discharge planning, which violated the resident's rights to refuse treatment without the threat of discharge.
Inaccurate PASARR Documentation for Residents
Penalty
Summary
The facility failed to ensure that the Pre-Admission Screening and Resident Review (PASARR) documents were accurate and reflective of the current conditions and diagnoses of the residents. This deficiency affected three residents out of the four reviewed for PASARR documents. For Resident #3, the PASARR document did not include diagnoses such as bipolar disorder, major depressive disorder, and post-traumatic stress disorder, despite these being present in the resident's medical record. Similarly, Resident #15's PASARR document omitted diagnoses like bipolar disorder, anxiety disorder, and adult failure to thrive, which were documented in her medical record. Resident #59's PASARR document was also found to be inaccurate as it did not include the diagnosis of insomnia, despite the resident being treated for it with Melatonin and other medications. The facility's policy requires coordination with the PASARR program to ensure residents with mental disorders or related conditions receive appropriate care. However, the social services director confirmed that the PASARR documents for these residents were not updated to reflect their current diagnoses, leading to the identified deficiency.
Failure to Update PASARR Documentation for Residents
Penalty
Summary
The facility failed to notify the state mental health agency of significant mental health changes for residents requiring Pre-Admission Screening and Resident Review (PASARR) updates. This deficiency affected three residents who had changes in their mental health diagnoses that were not communicated as required. Resident #3 had multiple mental health diagnoses, including bipolar disorder and major depressive disorder, which were not updated on her PASARR document. Similarly, Resident #15 had diagnoses such as bipolar disorder and anxiety disorder that were not reflected in her PASARR documentation. In both cases, there was no evidence in the progress notes to indicate that the state mental health agency had been informed of these significant changes. Resident #59 also experienced a deficiency in PASARR documentation. The resident's PASARR screening did not include the diagnosis of insomnia, despite it being a part of the resident's medical record and treatment plan. An interview with Social Services confirmed that the PASARR screening was inaccurate and had been sent to the Department of Aging without the necessary updates. The facility's policy requires coordination with the PASARR program to ensure residents with mental disorders receive appropriate care, but this was not adhered to, leading to the deficiencies noted.
Failure to Obtain Weekly Weights for Nutritional Monitoring
Penalty
Summary
The facility failed to ensure weekly weights were obtained per physician orders for two residents, leading to deficiencies in nutritional monitoring. Resident #92, who was admitted with multiple complex medical conditions including infective endocarditis, hepatitis, and a history of weight loss, had a physician order for weekly weight checks to monitor and maintain a stable weight. However, the facility only recorded one weight measurement on 11/12/24, despite the care plan and physician orders indicating the need for weekly monitoring. Interviews with facility staff confirmed the oversight in obtaining the required weekly weights. Resident #77, admitted with conditions such as end-stage renal disease and congestive heart failure, also had physician orders for weekly weight checks to establish a baseline due to significant weight fluctuations. The resident's weights showed a notable decrease from 200 pounds to 180.2 pounds over a short period, triggering dietary recommendations for continued weekly monitoring. Despite these orders and recommendations, the facility failed to record any weights after 02/10/25, which was necessary to verify the initial weight and monitor ongoing changes. The facility's policy on weight assessment and intervention, dated September 2012, outlines the requirement for weights to be measured on admission, the next day, and weekly for two weeks thereafter. However, the facility did not adhere to this policy, resulting in a lack of consistent weight monitoring for the residents involved. Interviews with the dietitian and corporate nurse confirmed the failure to obtain the necessary weekly weights, highlighting a gap in the facility's adherence to its own policies and physician orders.
Failure to Ensure Resident's Respiratory Needs with BiPap
Penalty
Summary
The facility failed to meet the respiratory needs of a resident who required a BiPap machine. The resident, admitted with chronic obstructive pulmonary disease, asthma, pulmonary embolism, and heart failure, was hospitalized and upon readmission to the facility, her BiPap orders were omitted. The resident was supposed to have BiPap orders for use at bedtime, as per physician orders, to prevent life-threatening risks. However, there was a gap in the orders from the time of her readmission until several days later, during which the necessary BiPap orders were not entered. This omission was confirmed by both the Director of Nursing and the Certified Nurse Practitioner, highlighting a lapse in ensuring the resident's critical respiratory care needs were met.
Deficiency in Dialysis Communication for Resident
Penalty
Summary
The facility failed to ensure ongoing communication between the facility and the dialysis vendor for a resident requiring dialysis services. This deficiency affected a resident with chronic kidney disease, end-stage renal disease, chronic viral hepatitis C, hypertension, and dependence on renal dialysis. The resident had a standing appointment for dialysis at an outside clinic three times a week, with orders for nursing staff to complete pre- and post-dialysis communication forms on specific days. However, observations revealed that some post-dialysis forms were incomplete in the resident's hard chart. Interviews with staff, including an LPN and the Director of Nursing (DON), highlighted lapses in communication. The LPN admitted that when the resident returned from dialysis without a communication sheet, there was no follow-up with the dialysis center to inquire about the services performed. Additionally, the DON confirmed that communication with the dialysis center needed to be more defined and expected nurses to read communications from the dialysis center. A review of the facility's undated Hemodialysis policy indicated that there should be ongoing communication between the dialysis center staff and the facility, including details on weight changes, medication administration, and treatment complications.
Lack of Parameters for As-Needed Pain Medication
Penalty
Summary
The facility failed to provide parameters for as-needed pain medication for a resident, which was identified during a medical record review and staff interview. The resident, who was admitted in March 2019, had a complex medical history including conditions such as acute bronchitis, epileptic seizures, PTSD, and pain, among others. The physician orders from December 2024 to March 2025 included acetaminophen, naproxen, and oxycodone for pain management, but lacked specific parameters indicating which medication should be administered based on the resident's pain level. The medication administration record showed that the resident received these medications at varying pain levels, with oxycodone being administered even at pain levels as low as 0. Interviews with the LPN and DON revealed that the facility did not have a standard practice for setting parameters for as-needed pain medications. Instead, the decision was left to the residents, with nurses asking about their pain levels and allowing them to choose their preferred medication. This lack of structured guidance led to the deficiency noted by the surveyors.
Failure to Secure and Administer Medications Properly
Penalty
Summary
The facility failed to secure and store medications appropriately, affecting one resident during the annual survey. The resident, who was cognitively intact and had a history of cerebral infarction, dysphagia, major depressive disorder, psychoactive substance abuse, disorientation, anxiety disorder, and pain, was observed with a medicine cup containing several tablets and capsules on the overbed table. There was no documented assessment or screening for self-medication, nor was there a physician's order for the resident to self-administer medications. An interview with the resident revealed that the medications might be his morning doses, which he needed to confirm with his nurse. The LPN confirmed that the medication cup with morning medications was left on the overbed table because the resident preferred to take medications after breakfast. The LPN did not realize the resident had not taken the medication yet. The Director of Nursing confirmed that the expectation is for nurses to follow professional standards of medication administration, which includes observing the patient take the medication at the time it is brought into the room. The facility's policy on administering medications, dated December 2012, aligns with these expectations.
Incomplete Investigations of Abuse and Misappropriation Allegations
Penalty
Summary
The facility failed to conduct thorough investigations and documentations of allegations of abuse and misappropriation involving three residents. Resident #94, who was cognitively intact, reported an incident where a CNA allegedly pushed him after being woken up for assistance. The facility initiated an investigation, but the documentation was incomplete, lacking a written or signed statement from the resident. The investigation relied on identical staff statements that did not recall specific events or interactions, and the facility's summary did not constitute actual evidence. Resident #86, also cognitively intact, reported inappropriate touching by another resident. The police were notified, and an investigation was initiated. However, the investigation documentation was insufficient, with no detailed statement from the resident and only a brief questionnaire with yes or no answers. The facility's investigation summary did not include a direct account from the resident, and the staff statements were identical and lacked specific details about the incident. Resident #95 reported a missing diamond earring, but there was no specific allegation of theft. The facility conducted interviews with like residents, but failed to provide evidence of interviews or statements from the resident or staff. The investigation documentation was incomplete, and the facility's summary did not include a direct account from the resident. The facility's policy required thorough investigations with documented evidence, but the investigations in these cases were incomplete and lacked necessary documentation.
Infection Control Deficiencies in Wound Care and Laundry Handling
Penalty
Summary
The facility failed to implement proper infection control procedures during a dressing change for a resident with multiple health conditions, including type 2 diabetes mellitus, HIV, pneumonia, and a staphylococcus infection. The resident required enhanced barrier precautions due to an indwelling medical device and a wound. During an observation, an LPN did not wear a gown as required and failed to wash hands between glove changes while performing wound care on the resident. The facility's policy on wound care and enhanced barrier precautions clearly outlined the need for gown and glove use during such procedures, which was not adhered to by the LPN. Additionally, the facility did not follow proper infection control procedures in handling soiled laundry. Due to an out-of-order elevator, laundry staff were observed throwing soiled laundry down a stairwell to a landing, where it was left until it could be collected and taken to the laundry room. Observations revealed unbagged and visibly soiled laundry on the stairwell, contrary to the facility's expectations for handling soiled laundry. Interviews with staff confirmed these practices, which did not align with the infection control procedures required to prevent contamination.
Plumbing Failure and Unsanitary Conditions in Shower Room
Penalty
Summary
The facility failed to maintain a safe, functional, and sanitary environment in the shower room located in the B hallway, which had the potential to affect all residents residing in the facility. The issue began with a plumbing failure that resulted in a shower drain backup, leading to emergency flooding over the course of three days. The plumbing company was called to address the issue, and although they initially removed a blockage, the problem persisted, causing severe flooding in the B hallway and affecting several resident rooms. Observations revealed that the shower room had multiple ceramic tiles on the floor, exposing wet wall material, and a three-inch hole behind the toilet. A brown substance with dried particles was noted in the shower stall, indicating unsanitary conditions. Interviews with residents and staff confirmed the presence of brown, foul-smelling water in the hallway and rooms, and the shower room was unusable for a period. The facility attempted to manage the situation by offering to relocate affected residents and providing emergency water sources and hygiene wipes during the water shut-off. The plumbing company returned to the facility to further investigate and repair the issue, discovering that the blockage was caused by washcloths and fabric debris. Despite the restoration of water flow and the shower room being placed back into service, the structural issues, such as the hole in the wall and loose tiles, remained unaddressed. The facility's maintenance policy requires maintaining the building in a safe and operable manner at all times, which was not upheld in this instance.
Neglect in Fire Response
Penalty
Summary
The facility failed to ensure a resident was free from neglect when staff did not timely implement fire procedures during a fire incident in a resident's room. The fire occurred in the resident's room, igniting the mattress and bedding, which activated the fire alarm and sprinkler system. Despite the alarm, staff did not immediately implement fire protocols to rescue, contain, or extinguish the fire. The delay in response resulted in the resident sustaining burns to her legs, torso, and arm, and she was transferred to the hospital for treatment of extensive burns and acute respiratory failure. The resident involved had a history of chronic obstructive pulmonary disease, peripheral vascular disease, depression, anxiety, and suicidal ideation. She was cognitively intact but required assistance with personal hygiene, dressing, and transfers. The resident was a supervised smoker, and her smoking materials were supposed to be stored by the facility for safety. However, the resident intentionally started the fire to get staff's attention, using a lighter to ignite the fire on her bed. The facility's investigation could not determine how the resident obtained the lighter. Video footage and staff interviews revealed that multiple staff members walked past a fire extinguisher without attempting to use it, and they did not evacuate other residents or close room doors to contain the fire. The staff's inaction and failure to follow fire safety protocols placed the resident and others in the smoke compartment at risk of serious harm. The facility's response to the fire was inadequate, as staff did not promptly rescue the resident or effectively manage the fire situation.
Removal Plan
- The fire alarm sounded which transmits an alarm to the fire department of the fire.
- The facility's incident investigation indicated Licensed Practical Nurse (LPN) #251 called 911 to report the incident of fire.
- Residents are seen via facility video camera footage to be directed out of their rooms and attempting to make their way off the hallway.
- LPN #251 was observed via video footage to take a fire extinguisher into the resident's room B05, identified as Room B05.
- The facility had completed a head count of residents, and all 90 residents were accounted for.
- The Columbus Fire Department exited the facility, and a Fire Watch was initiated and completed by the Administrator and DON.
- Respiratory Assessments were initiated by Unit Manager/ LPN #225, and LPN #203 on Residents #17, #20, #18, #15, #21, #23, #22, #16, and #11, who resided in the same smoke compartment where the fire was located, with no adverse reactions noted.
- Cleaning of the fire debris in Room B05 and the adjacent hall area began by Maintenance Director #390 and Regional Environmental Services #805.
- All residents who lived in the smoke compartment where the fire occurred were temporarily moved to open rooms in the B and C halls.
- Four sprinkler heads were replaced in Room B05 by Fire Safety Company #800 to maintain safety in the building and restore water to the facility.
- All 88 residents were interviewed for post incident safety, conducted by Admissions, Licensed Social Worker (LSW) #270 and Human Resource Director #259.
- The Fire Department inspected the facility and cleared the facility from Fire Watch.
- The two fire extinguishers that were used and deployed during the fire were replaced by Maintenance Director #390.
- All department managers were educated by the Regional Director of Clinical Services (RDCS) #810 on the Smoking Policy, Change in Condition Policy, Fire safety (RACE & PASS), and Abuse and Neglect Policy.
- An all-staff education was initiated by Department Managers and the DON for the facility's employees.
- All 88 resident rooms were searched by the Department Managers for smoking contraband.
- All 88 residents were assessed by Unit Manager LPN#225, Unit Manager LPN #579, and Registered Nurse (RN) #820 for a change in condition.
- A Fire Drill was conducted by Maintenance Director #390 without incident.
- The Fire Marshall was notified by the Administrator of the incident of fire via the Fire Marshall's electronic portal.
- A second Respiratory Assessment was initiated on Residents #17, #20, #18, #15, #21, #23, #22, #16, and #11.
- A Quality Assurance and Performance Improvement (QAPI) meeting was held with the Administrator, RDCS #810, LSW #270, Maintenance Director #390, Unit Manager LPN #225, Human Resources #259, Therapy Director #825, Business Office Manager #830, Activity Director #268, Dietary Manager #835, Medical Records/Central Supply #840, Assistant Director of Dietary #845, Housekeeping Manager #850, and Medical Director #900.
- Resident Smoke Breaks- five times a week for four weeks, then one time a week for four weeks, completed by the DON.
- Room Sweeps for Smoking Materials- three times per week for four weeks and one time a week for four weeks, completed by the Departmental Managers.
- Fire Drills on Each Shift - weekly for eight weeks (7a-7p and 7p-7a), completed by Maintenance Director #390.
- Assess/Re-educate as needed - staff knowledge of Fire Safety RACE/PASS - weekly/per shift times eight weeks, completed by Maintenance Director #390.
Failure to Enforce Smoking Policy Leads to Resident Fire Incident
Penalty
Summary
The facility failed to ensure a safe environment for a resident who utilized oxygen therapy and smoked cigarettes, leading to a fire in the resident's room. The resident, who was cognitively intact but required supervision with smoking, was found to have smoking materials, including cigarettes and a lighter, in her room. This was against the facility's smoking policy, which required smoking materials to be stored by the facility. The fire, which occurred in the resident's room, resulted in severe burns to the resident and posed a risk to other residents in the same smoke compartment. The resident had a history of chronic obstructive pulmonary disease and required oxygen therapy. Despite being assessed as needing supervision while smoking, the resident was able to access smoking materials and a lighter, which led to the ignition of her mattress and bedding. The fire department's investigation concluded that the fire was accidental, caused by smoking materials in close proximity to high-concentration oxygen. The resident was transferred to the hospital with extensive burns and acute respiratory failure. Interviews with staff and residents revealed that the facility did not consistently enforce its smoking policy, allowing residents to keep smoking materials in their rooms. Several residents confirmed that they were not required to hand in their smoking materials, and staff interviews indicated a lack of adherence to the policy. The facility's failure to monitor and control the possession of smoking materials by residents who required supervision directly contributed to the incident.
Removal Plan
- The fire alarm sounded which transmits an alarm to the fire department of the fire.
- The facility's incident investigation indicated Licensed Practical Nurse (LPN) #251 called 911 to report the incident of fire.
- Residents are seen via facility video camera footage to be directed out of their rooms and attempting to make their way off the hallway.
- LPN #251 was observed via video footage to take a fire extinguisher into the resident's room, identified as Room B05.
- Resident #19 was observed on the video footage being brought out of Room B05 in the bed and was pushed down the hallway by LPNs #251 and #444, and STNA #248 with Police Officers following.
- The facility had completed a head count of residents, and all 90 residents were accounted for.
- The Columbus Fire Department exited the facility, and a Fire Watch was initiated and completed by the Administrator and DON.
- Respiratory Assessments were initiated by Unit Manager/LPN #225, and LPN #203 on Residents #17, #20, #18, #15, #21, #23, #22, #16, and #11, who resided in the same smoke compartment where the fire was located, with no adverse reactions noted.
- Cleaning of the fire debris in Room B05 and the adjacent hall area began by Maintenance Director #390 and Regional Environmental Services #805.
- All residents who lived in the smoke compartment where the fire occurred were temporarily moved to open rooms in the B and C halls.
- Four sprinkler heads were replaced in Room B05 by Fire Safety Company #800 to maintain safety in the building and restore water to the facility.
- All 88 residents were interviewed for post incident safety, conducted by Admissions, Licensed Social Worker (LSW) #270 and Human Resource Director #259.
- The facility smoking policy was reviewed and revised by [NAME] President of Clinical services #340 to make all smoking supervised and all smokers have to submit smoking articles to staff.
- The Fire Department inspected the facility and cleared the facility from Fire Watch.
- The two fire extinguishers that were used and deployed during the fire were replaced by Maintenance Director #390.
- All department managers were educated by the Regional Director of Clinical Services (RDCS) #810 on the Smoking Policy, Change in Condition Policy, and Fire Safety (RACE & PASS) Policy.
- An all-staff education was initiated by Department Managers and the DON for the facility's employees.
- The Administrator held a meeting with the 50 residents who smoke to review and sign the revised Smoking Policy and smoking process.
- Smoking assessments began on all residents that currently smoke by Unit Manager LPN #579 and Unit Manager LPN #225.
- All 88 resident rooms were searched by the Department Managers for smoking contraband.
- All 88 residents were assessed by Unit Manager LPN #225, Unit Manager LPN #579, and Registered Nurse (RN) #820 for a change in condition.
- A Fire Drill was conducted by Maintenance Director #390 without incident.
- The Fire Marshall was notified by the Administrator of the incident of fire via the Fire Marshall's electronic portal.
- A second Respiratory Assessment was initiated on Residents #17, #20, #18, #15, #21, #23, #22, #16, and #11.
- The care plans of residents who were previously unsupervised smokers were revised to now being supervised smokers by Minimum Data Set (MDS) LPN #855.
- A Quality Assurance and Performance Improvement (QAPI) meeting was held with the Administrator and other key staff.
- Resident Smoke Breaks - five times a week for four weeks, then one time a week for four weeks, completed by the DON.
- Room Sweeps for Smoking Materials - three times per week for four weeks and one time a week for four weeks, completed by the Departmental Managers.
- Fire Drills on Each Shift - weekly for eight weeks (7a-7p and 7p-7a), completed by Maintenance Director #390.
- Assess/Re-educate as needed - staff knowledge of Fire Safety RACE/PASS - weekly/per shift times eight weeks, completed by Maintenance Director #390.
Failure to Implement Fire Protocol and Report Incident
Penalty
Summary
The facility failed to report an incident of potential neglect when it did not timely implement fire protocol during a fire in a resident's room. The incident involved Resident #19, who had a fire in her room, and it had the potential to affect nine other residents living in the same smoke compartment. The facility's staff did not follow the fire safety procedures, which included rescuing residents, containing the fire, and evacuating residents. Resident #19, who was cognitively intact and dependent on staff for various daily activities, suffered third-degree burns to her legs during the incident. The fire alarm was activated, and staff members were observed on video footage failing to take immediate action to extinguish the fire or evacuate residents. Staff walked past a fire extinguisher multiple times without using it and did not assist residents in evacuating the hallway filled with smoke. The facility's Regional Director of Operations confirmed that the staff did not follow the fire safety policy and procedures. The facility did not submit a self-reported incident regarding the fire until after a review of the video footage, which showed that the staff's response was inadequate. The facility's policy required immediate reporting of such incidents to the Administrator and the Ohio Department of Health, which was not done in a timely manner.
Facility's Ineffective Resource Management Leads to Fire Incident
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, leading to a significant incident involving a fire in a resident's room. The fire occurred when a resident, who was supposed to have her smoking materials stored by the facility, was found with a lighter and cigarettes, which she used to ignite her bed. This resulted in the resident sustaining severe burns and requiring hospitalization. The facility did not report the incident as an injury of unknown origin or potential neglect to the State Survey Agency in a timely manner. The investigation into the fire incident was inadequate, as the facility did not thoroughly review all available camera footage, which later revealed a delay in staff response to the fire. The staff failed to follow established fire safety procedures, such as using fire extinguishers and closing doors to contain the fire. Interviews with staff and residents indicated that the facility's smoking policy was not enforced prior to the incident, allowing residents to keep smoking materials in their possession unsupervised. Additionally, the facility's emergency preparedness training was insufficient, with only a portion of the staff receiving education on fire safety procedures. Some staff members were unable to recall the training or the meaning of fire safety acronyms. The facility's failure to implement its smoking policy and emergency procedures contributed to the severity of the incident, placing multiple residents at risk.
Failure to Implement Fall Interventions for High-Risk Resident
Penalty
Summary
The facility failed to ensure that fall interventions were in place for a resident identified as high risk for falls. Resident #22, who was admitted with diagnoses including seizures, delirium, hemiplegia, and mild cognitive impairment, was assessed using the Morse Fall Scale and determined to be at high risk for falling. The care plan for this resident included specific fall interventions such as bright colored tape on the call light, a defined perimeter mattress, non-skid footwear, a fall mat on the right side of the bed, and keeping the bed in the lowest position with the call light within reach. During an observation, it was noted that several of these interventions were not in place. The resident's bed was not in the lowest position, non-skid footwear was not worn, and the call light was not within reach nor marked with bright colored tape. An LPN confirmed these observations, noting that the resident did not like to wear socks to bed and that the bed was elevated for lunch. The facility's policy on falls, dated 09/2012, requires staff to implement and monitor interventions to prevent falls, which was not adhered to in this instance.
Infection Control Deficiencies in Medication Administration and Wound Care
Penalty
Summary
The facility failed to maintain proper infection control measures during medication administration for Resident #22. The resident, who was admitted with diagnoses of respiratory failure and muscle weakness, was dependent on staff for activities of daily living, including medication administration. During an observation, a registered nurse dispensed Gabapentin capsules into her bare hand before placing them into a medication cup for administration to the resident. This action was confirmed by the nurse during an interview, acknowledging that she should not have touched the resident's oral medications with her bare hands. The facility's policy on administering medications requires staff to follow established infection control procedures, which were not adhered to in this instance. Additionally, the facility failed to implement enhanced barrier precautions (EBP) for Resident #28, who had an open coccyx wound. The resident, admitted with diagnoses including protein calorie malnutrition and muscle weakness, required assistance with activities of daily living and had intact cognition. During a wound care observation, nurses did not don gowns prior to completing the dressing change, despite the presence of personal protective equipment in the resident's room. Interviews with nursing staff and the Director of Nursing confirmed that there was no order for EBP related to the resident's open wound, and that gowns should have been worn during dressing changes. The facility's policy on EBP indicates that such precautions are necessary for residents with open wounds, regardless of their multi-drug resistant organism status.
Facility Maintenance and Cleanliness Deficiencies
Penalty
Summary
The facility was found to be in a state of disrepair and uncleanliness, affecting all 87 residents. During a survey, it was observed that various areas of the facility were not maintained in a clean, homelike environment. Specific issues included a missing transition strip to the dining room, dirty and chipped door frames, peeling wallpaper, rusting ceiling vents, and splatter marks on walls. Additionally, the therapy gym had a chipping door with a sharp edge and stained wallpaper. The C hallway had dirty floors with mud and tire marks, and the B hallway had a bathroom door splattered with a brown substance and rusted vents. The downstairs counseling space had exposed dirty brick due to missing drywall, and the staff lounge was closed due to renovations after a water leak and mold-like substance were identified. The facility's maintenance issues extended to safety hazards, as employees were exposed to slip, trip, and fall hazards from leaking pipes, and potential health hazards from untreated mold accumulation. The facility failed to provide a policy for maintaining a safe and sanitary environment. The report also noted that a sink in room B27 had been broken for three months before being repaired. These deficiencies were investigated under Complaint Number OH00154570, highlighting the facility's failure to maintain a safe, clean, and comfortable environment for residents, staff, and the public.
Failure to Assist Resident with Personal Hygiene
Penalty
Summary
The facility failed to assist a female resident with shaving her face, which was necessary for her personal hygiene. The resident, who was admitted with diagnoses including cerebral infarction, hemiplegia, hemiparesis, depression, chronic obstructive pulmonary disease, and type II diabetes, was dependent on staff for personal hygiene tasks. Despite having intact cognition and not refusing care, the resident had not been shaved since her admission due to a lack of supplies. This was confirmed during an observation and interview, where the resident expressed embarrassment over her facial hair. The Director of Nursing acknowledged the resident's facial hair but stated that the resident was not bothered by it. The facility's policy indicated that staff should assist with grooming as needed, but this was not adhered to in this case.
Failure to Administer Seizure Medication
Penalty
Summary
The facility failed to ensure that medications were administered without significant errors, affecting a resident with a seizure disorder, COPD, and dependence on a respirator. The resident was readmitted to the facility on 02/14/24 with an order for valproic acid solution to be administered three times daily via a gastrostomy tube. However, due to a transcription error by the admitting nurse, the medication order was not entered into the electronic medical record (EMR), resulting in the resident not receiving the prescribed medication from 02/14/24 through 03/13/24. The resident was subsequently readmitted to the hospital on 03/14/24 with seizure activity. The hospital staff noticed that valproic acid solution was missing from the resident's medication list. The facility's Director of Nursing confirmed the medication error and the failure to administer the medication as ordered. The facility's policy requires that medications be administered as ordered by the physician, which was not followed in this case. This deficiency was investigated under Complaint Number OH00152209.
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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) |
|---|---|---|---|---|
| Ohio Living Westminster-thurber | 0.4 mi | ★★★★★ | 6 | 0 |
| Majestic Care Of Columbus Llc | 1.5 mi | ★★★★★ | 6 | 0 |
| Scioto Pointe | 2.4 mi | ★★★★★ | 21 | 0 |
| First Community Village Healthcare Ctr | 2.7 mi | ★★★★★ | 0 | 0 |
| Bella Terrace Rehabilitation And Nursing Center | 3 mi | ★★★★★ | 4 | 1 |
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