Average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Columbus Alzheimer's Care Ctr during CMS and state inspections, most recent first.
Food storage and dishwashing sanitation deficiencies were identified when opened and outdated food items were found in dry storage and the walk-in refrigerator, including items with missing open dates and expired labeling. Staff were also observed washing resident breakfast dishes while the dish machine’s final rinse tested below the required 50 ppm chlorine level, which the Dietary Director confirmed.
A resident with Alzheimer’s disease, dementia, and moderate cognitive impairment had morning medications left unsupervised in a plastic cup on the nightstand, and an LPN later administered them. Surveyors also found loose pills in medication cart drawers, including identified meds such as olanzapine, aspirin, memantine, amlodipine, Eliquis, and galantamine, contrary to the facility’s medication storage policy.
Conflicting code status documentation was found for two residents with dementia-related diagnoses. For one resident, the chart showed full code in one document, DNR-CC in physician orders, and full code in the code status book; for another resident, physician orders listed DNRCC, but the chart and code status book contained conflicting DNRCC and DNRCC-A information. An ADON confirmed the discrepancies and stated they could confuse nurses.
Care plans were not accurate or updated for three residents. One resident with dementia, PTSD, and a history of medication hoarding and suicide attempts had meds found in the room, but the care plan did not include interventions to address swallowing meds or room sweeps, and it did not reflect known behavior triggers. Another resident had documented sexualized behaviors toward other residents, but the care plan did not include that history. A third resident’s care plan incorrectly listed PTSD and trauma triggers even though the MDS, psychosocial assessment, MDS coordinator, and DON confirmed no PTSD diagnosis.
A resident with severe cognitive impairment, dementia, venous insufficiency, and chronic left lower extremity ulcers had physician-ordered wound care and topical cream treatments that were repeatedly not documented as completed or refused on the TAR. The resident’s care plan noted resistive behavior and noncompliance, but progress notes and behavior monitoring did not document the missed treatments or refusals, and the ADON, an LPN, and the MDS coordinator confirmed the record lacked evidence of completion or refusal.
Failure to administer ordered oxygen. A resident with Alzheimer's disease, dementia, and chronic respiratory failure had an order for continuous O2 at 4 L/min via NC, but during observation the NC was not on the resident's face and was hanging from a dresser handle, while the concentrator was set at 2 L/min. An MDS Coordinator confirmed the resident was not wearing oxygen and the flow rate was incorrect.
Insulin Pen Not Primed Before Administration: A resident with DM and severe cognitive impairment received insulin aspart sliding scale coverage, but an LPN observed during administration did not prime the insulin pen before giving the injection. The LPN confirmed the omission, and the DON later confirmed the pen must be primed before use per manufacturer guidance.
Failure to use required PPE for a resident on contact precautions occurred when staff entered the room without gowns and gloves, and one aide left and re-entered the room with the same gloves while retrieving a Hoyer lift. The resident had an open stump wound colonized with CRAB and MRSA, and an LPN confirmed the staff were supposed to be wearing gowns and gloves for care activities.
A resident with severe cognitive impairment was injured after being pushed by another resident, leading to a fall and a right femur fracture. The incident occurred when the injured resident wandered into the other resident's room, despite existing care plans to prevent such interactions. The facility's investigation concluded there was no intent to harm, but the incident highlights a failure to protect residents from physical abuse.
The facility failed to investigate and document allegations of abuse, neglect, and misappropriation for several residents. Incidents included injuries of unknown origin and resident-to-resident altercations, with missing or incomplete documentation of required 15-minute checks. The Director of Nursing acknowledged these deficiencies, which were not in line with the facility's policy for handling such allegations.
A resident's wedding ring was reported missing by family to a Unit Manager, who failed to report the incident to management or initiate an investigation promptly. The delay led to non-compliance with the facility's policy requiring timely reporting of misappropriation to the state health department.
The facility failed to ensure call lights were accessible for two residents, affecting their ability to summon assistance. One resident's call light was hung behind the headboard, while another's was on the floor under the bed. A nurse confirmed the call lights should have been within reach. The Administrator and DON were unsure if a policy on call light accessibility existed.
The facility failed to ensure a qualified Activity Director was in place, as the current AD lacked the necessary certification, degree, and experience. Despite being promoted to Activities Manager, the AD had only six months of full-time experience and no supervisory experience, relying on online resources for planning activities. This deficiency potentially affected all 99 residents.
The facility failed to properly label and store medications and secure medication carts. Two RNs left their carts unlocked while administering medications, violating facility policy. A resident's eye drops lacked an opening date, contrary to guidelines. Additionally, improper storage of a tuberculin solution and influenza vaccine was observed, risking medication errors.
The facility failed to prevent contamination of clean utensils, maintain kitchen equipment, and follow datemarking procedures. Observations revealed chipped paint above clean pots, a leaking garbage disposal, and expired or undated food items. Additionally, a noncommercial microwave with peeling metal and a reach-in cooler with pooling water were noted, with no work orders submitted for these issues.
The facility's assessment was incomplete, missing critical information on ethnic, cultural, or religious factors, third-party agreements, health IT resources, and risk assessments. Interviews confirmed the presence of residents with language needs not documented in the assessment, and the QAPI meeting did not address these deficiencies.
The facility failed to maintain a clean and homelike environment for several residents, as observed during a survey. Rooms were found to be filthy, with sticky floors, soiled bedspreads, and stained walls. Other rooms lacked personal items or decorations, making them appear bare and uninviting. These conditions were confirmed by facility staff, indicating a failure to adhere to the facility's policies on cleanliness and homeliness.
A LTC facility reported a 12.9% medication error rate, affecting four residents. A resident missed a Namenda dose due to unavailability, another received a partial Zoloft dose, a third was given the wrong laxative, and a fourth had insulin administered without priming the pen. These errors were against facility policies.
The facility failed to ensure proper infection control practices, including the absence of signage and PPE for residents on enhanced barrier precautions, improper wound care procedures by an LPN, and inadequate glove use and hand hygiene by staff. These deficiencies affected multiple residents with specific medical needs.
A facility failed to manage a resident's financial affairs by missing a scheduled life insurance payment, leading to the policy's cancellation. The resident, with dementia and Alzheimer's, was unable to manage their own finances, and the facility's business office was responsible for making quarterly payments. Despite previous payments being made, the April payment was missed, and efforts to reinstate the policy were ongoing.
A resident with an open wound and cognitive intactness had a wound culture showing heavy growth of streptococcus pyogenes. The results were available, but the physician was not notified until two days later, contrary to the facility's policy requiring immediate notification. An LPN confirmed the delay in notification.
A resident with dementia and aphasia, who spoke French Creole, was not provided with necessary communication aids like an interpreter or communication board, despite these being part of her care plan. Staff admitted to guessing her needs due to the language barrier. Another resident with multiple health issues was observed with unkempt hair over several days, indicating a failure to provide necessary personal hygiene care. The facility's policy on supporting ADLs was not followed, as staff did not implement the required interventions for these residents.
The facility failed to provide activities that met the needs and preferences of several residents, including one with dementia and another with Alzheimer's disease. Residents expressed dissatisfaction with the lack of activities and opportunities to go outside, and activity logs showed minimal engagement. Staff interviews revealed a lack of awareness of residents' preferences and a failure to invite them to activities, contributing to feelings of unhappiness and isolation.
A facility failed to follow physician orders for daily weight monitoring of a resident with CHF, Alzheimer's, and other conditions. The resident's care plan required daily weights at 6:00 A.M., with significant weight changes reported. However, weights were not documented on three occasions, as confirmed by the Unit Manager.
A resident with dementia and visual impairments was not consistently assisted with wearing his corrective lenses, despite needing them for clear vision. Observations showed the resident without glasses on multiple occasions, and staff were often unaware of his need for them. The glasses were frequently found out of reach, and staff had to assist the resident in wearing them, which improved his vision.
The facility failed to maintain pressure ulcer interventions for three residents. One resident was observed without a pressure-reducing cushion, another without heel elevators, and a third with an incorrectly set mattress. Staff were unaware of the correct settings and equipment, leading to non-compliance with physician orders.
A facility failed to administer tube feedings at the physician-ordered rate for a resident with severe protein calorie malnutrition and other medical conditions. The resident was supposed to receive Isosource 1.5 at 55 cc per hour, but was observed receiving Jevity 1.5 at 50 cc per hour, as confirmed by the UM.
A resident with type two diabetes received insulin injections outside the physician's specified parameters, as confirmed by the DON. The facility's policy required verification of medication administration, but insulin was administered incorrectly on multiple occasions.
The facility did not have transfer agreements with hospitals certified by Medicare or Medicaid, potentially affecting all 99 residents. The facility only had agreements to transfer residents to sister facilities in emergencies. Interviews confirmed that a written transfer agreement was not executed until late August, indicating a failure to ensure timely hospital transfers for residents.
Food Storage and Dishwashing Sanitation Deficiencies
Penalty
Summary
Food was not stored in a safe and sanitary manner and dishes were not washed in accordance with the facility’s sanitation standards. In the dry storage room, individual servings of sweet and sour sauce were found labeled as opened on 06/06/26 with a use-by date of 06/26/26. In the walk-in refrigerator, a tray of diced peppers was labeled best by 06/30/26, a 5-pound tub of sour cream was opened and partially full with no open date, and an opened, partially full 25-pound tub of hard-boiled eggs had a delivery date of 06/11/26 and no open date. The Dietary Director confirmed these findings during interview, and the facility policy stated that opened goods with no date are to be discarded and outdated goods are to be discarded the day after expiration. In addition, staff were observed washing residents’ breakfast dishes while the dishwashing machine’s final rinse registered less than 50 parts per million on chlorine test strips, and the Dietary Director confirmed the machine was not reaching the required chlorine level.
Improper Medication Storage and Loose Pills in Medication Carts
Penalty
Summary
The facility failed to properly store medications for a resident who had Alzheimer’s disease with late onset, muscle weakness, dementia in other diseases classified elsewhere moderate, and anxiety. The resident’s records showed she was not capable of self-administering medications, required dementia-related care in a secured area, and had a BIMS score of 08 indicating moderate cognitive impairment. Despite this, observation on 07/07/26 at 8:26 A.M. found unsupervised medication in a plastic cup on the resident’s nightstand next to her bed, and an LPN confirmed the medication was the resident’s morning medications and administered them at that time. The facility also failed to keep medication carts free of loose medications. On 07/09/26, observation with the ADON identified 11 whole pills, one half pill, and two quarter pills in cart #1 drawer #2, including identified medications such as olanzapine, aspirin, memantine hydrochloride, and amlodipine, along with several unidentifiable pills. A separate observation the same day found five loose pills in cart #3 drawer #2, including Eliquis, memantine, and galantamine, with one pill unidentifiable. The facility policy stated medications were to be stored in original labeled containers and in a locked cabinet, cart, or medication room accessible only to authorized personnel.
Conflicting Code Status Documentation
Penalty
Summary
The facility failed to clearly identify resident code statuses for two residents reviewed for advance directives. Resident #05 had diagnoses including Alzheimer's disease, dementia, and neurocognitive Lewy body disease. The medical record contained a document dated 09/25/25 indicating full code status, but the physician orders dated 05/11/26 listed the resident as DNR-CC. The code status book identified Resident #05 as full code, and the Assistant Director of Nursing confirmed that the orders and code status book were conflicting and could confuse nurses. Resident #77, who had diagnoses including Alzheimer's disease, dementia, and type 2 diabetes mellitus, also had conflicting code status information. Physician orders dated 06/10/25 listed the resident as DNRCC, while the medical record documents section contained both a DNRCC and a DNRCC-A document, with the DNRCC-A form signed by a physician placed near the top and easily found, and the DNRCC form near the end of the uploaded documents. The code status book identified Resident #77 as DNRCC-A, and the Assistant Director of Nursing confirmed that the code statuses were conflicting and had the potential to confuse nurses. Facility policy required advance directive documents to be maintained in the medical record and changes in resident choices to be documented and communicated to staff providing care.
Care Plans Not Accurate or Updated for Resident Needs
Penalty
Summary
Care plans were not updated and did not accurately reflect assessed needs for three residents. For one resident with dementia, PTSD, alcohol dependence in remission, and aphasia, the record showed medications were found in the room on two occasions, the physician noted a history of suicide attempts using medications and prior medication hoarding, and staff were instructed to ensure medications were swallowed and to complete intermittent room sweeps. However, the care plan did not include interventions for medication hoarding, suicide attempts using medications, or the need to verify that medications were swallowed. The same resident’s behavior care plan also did not reflect triggers related to her children and their lack of visits, which the DON confirmed staff should avoid discussing. For another resident with vascular dementia and anxiety disorder, the record showed two incidents of sexual conduct with another resident, including one incident in which the resident was found in a male resident’s room half naked with his penis in her mouth. The care plan addressed wandering into other residents’ rooms and grabbing at others’ bottoms, but did not reflect the resident’s history of sexualized behaviors toward other residents. For a third resident with vascular dementia, psychotic disorder with delusions, and traumatic subdural hematoma, the care plan stated the resident had PTSD related to being a veteran of war and included an intervention to identify trauma triggers, but the MDS, psychosocial assessment, MDS coordinator, and DON confirmed the resident did not have PTSD and had no known triggers for physical behaviors.
Failure to Document Ordered Wound Treatments
Penalty
Summary
The facility failed to ensure physician-ordered wound treatments were documented as completed or refused for one resident with severe cognitive impairment, Alzheimer’s disease, vascular dementia, venous insufficiency, and chronic wounds of the left lower extremity. The resident had orders for daily Altractain cream to the left lower extremity and, later, daily wound care for two venous ulcers that included acetic acid soaks, Atractain cream to the periwound, crushed Flagyl to the wound bed, silicone-bordered super absorber dressings, rolled gauze, and compression with Tubi-Grip. The resident’s care plan identified resistive behavior and noncompliance, including resistance to removing leg wound dressings, and the wound care plan directed staff to complete treatments as ordered and monitor the wounds until resolved. Review of the TAR showed multiple dates across April, May, June, and early July when Altractain cream and the wound treatments for both ulcers were not documented as completed or refused. Progress notes from the same period did not document missed treatments or refusals, and behavior monitoring did not identify missed wound treatments or refusals as behavioral symptoms. The ADON, an LPN, and the MDS coordinator each confirmed the record lacked evidence that the treatments were completed or refused, and staff stated the resident frequently refused treatment. The facility wound care policy required staff to document completion of treatments and document refusals, including the reasons for refusal, in the electronic medical record.
Failure to Administer Ordered Oxygen
Penalty
Summary
The facility failed to administer oxygen as ordered for Resident #24, who had diagnoses including Alzheimer's disease, dementia with mood disturbance, and chronic respiratory failure. The physician order dated 09/25/24 directed oxygen at 4 liters per minute via nasal cannula continuously, and the care plan identified altered respiratory status related to COPD with interventions to administer oxygen as ordered. During an observation on 07/06/26 at 10:34 A.M., Resident #24's oxygen tubing was not on his face, the nasal cannula was hanging from a dresser pull handle, and the oxygen concentrator was running at 2 liters per minute instead of the ordered 4 liters per minute. An interview with the MDS Coordinator confirmed that the resident was not wearing oxygen and that the concentrator was not set to the correct flow rate.
Insulin Pen Not Primed Before Administration
Penalty
Summary
The facility failed to ensure insulin was primed prior to administration for one resident who was observed receiving medication. Resident #3 had diagnoses including encephalopathy, Alzheimer's disease, diabetes mellitus, and acute kidney failure, and was severely cognitively impaired with orders for insulin injections seven days a week. The physician ordered insulin aspart sliding scale coverage before meals, and the resident's blood sugar was documented at 331 mg/dl, with 10 units of insulin administered per the MAR. During observation of the insulin administration, the LPN obtained the blood sugar reading, prepared the insulin pen by attaching the needle and dialing the dose to 10 units, but did not prime the pen before giving the injection. The resident was then wheeled to the room and the insulin was administered without priming. The LPN confirmed priming was not completed, and the DON later confirmed the nurse had not primed the pen and that the pen must be primed prior to dialing the dose. Manufacturer prescribing information for Novolog FlexPen instructed to select two units, hold the pen with the needle pointing upward, tap to raise air bubbles, press and hold the dose button until the counter shows 0, and verify a drop of insulin appears at the needle tip before use.
Failure to Use Required PPE for Resident on Contact Precautions
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when staff did not maintain appropriate PPE for a resident on contact precautions. Resident #06 had diagnoses including vascular dementia, type two diabetes, and peripheral vascular disease, and the care plan identified contact precautions related to an open left stump wound that was colonized with carbapenem resistant Acinetobacter baumanii and had MRSA in the wound. The care plan directed staff to use a gown and gloves for high-contact care activities such as dressing, bathing, transferring, hygiene, device care, and wound care requiring dressings. The resident also had a Brief Interview of Mental Status score of 08, indicating moderate cognitive impairment. Observation showed an unknown aide entering the resident's room without PPE, while another aide was already in the room wearing gloves but not a gown. One aide was observed wearing gloves, leaving the room to get a Hoyer lift, then re-entering the room with the same gloves and no gown. An LPN confirmed both staff should have had gloves and gowns on while assisting the resident and confirmed neither staff member had the proper PPE, including the aide who left the room and returned with the Hoyer lift while still wearing the same contaminated gloves. The facility policy stated that contact precautions require gown and gloves upon entering the room and that PPE must be removed and hand hygiene performed before leaving the room.
Resident-to-Resident Altercation Results in Injury
Penalty
Summary
The facility failed to protect Resident #100 from physical abuse by another resident, Resident #57, resulting in actual harm. On 02/03/25, Resident #57, who had a history of resident altercations and impaired cognition, pushed Resident #100, causing a fall and a right femur fracture. This incident occurred when Resident #100 wandered into Resident #57's room, leading to the altercation. Both residents were assessed for injuries, and Resident #100 was immobilized on the floor due to an obvious range of motion deficit to the right hip and was subsequently transferred to the hospital. Resident #100 had severe cognitive impairment and was independent for mobility, with a history of Alzheimer's disease, vascular dementia, and other conditions. The care plan for Resident #100 included interventions to monitor his safety and redirect him away from areas where he might encounter Resident #57. Despite these measures, Resident #100 was found lying on the floor near Resident #57's room, in pain, and was given pain medication before being taken to the hospital, where he was diagnosed with a right hip fracture. Resident #57, who also had severe cognitive impairment, was known to be resistive to care and had a history of aggression towards male residents entering his room. His care plan included interventions to manage his behavior, such as psychiatric evaluations and maintaining consistency in his routine. After the incident, Resident #57 was placed on 15-minute checks, and the facility's investigation concluded that the incident was not abuse, as both residents were reacting impulsively without intent to harm. However, the facility's policy on abuse requires protection of residents from such incidents, indicating a failure to ensure a safe environment for Resident #100.
Failure to Investigate and Document Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to thoroughly investigate and implement interventions for allegations of abuse, neglect, misappropriation, and injuries of unknown origin affecting eight residents. For Resident #54, an injury of unknown origin was reported, but no resident interviews or statements were completed, and the intervention of 15-minute checks was not documented as completed. The Director of Nursing acknowledged the lack of evidence for these checks, which were not typical for such an injury. For Resident #89, investigations into misappropriation involving a missing wedding ring and clothes were incomplete, lacking resident interviews and specific questions asked of staff. The investigation mixed information from a previous incident and did not document interactions with the Ohio Department of Health. The facility also failed to consider staff working prior to the allegation date. The Director of Nursing admitted these oversights during the interview. Other residents, including #52, #100, #33, #48, #20, and #21, were involved in incidents of resident-to-resident altercations. The facility did not complete resident interviews or statements, and 15-minute checks were either missing or inconsistently documented. The Director of Nursing confirmed the missing documentation and acknowledged the discrepancies in the records. The facility's policy required immediate reporting and thorough investigation of such allegations, which was not adhered to in these cases.
Failure to Timely Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an allegation of misappropriation of a resident's property to the state agency in a timely manner. This incident involved a resident with cognitive impairments, including dementia and aphasia, who required extensive assistance with daily activities. The resident's family reported a missing wedding ring to the Unit Manager before Christmas, but the Unit Manager did not inform facility management or initiate an investigation promptly. The Unit Manager attempted to locate the ring but did not escalate the issue to management, as the usual staff were unavailable, and then went on vacation. The delay in reporting the incident to the Director of Nursing and subsequently to the Ohio Department of Health resulted in non-compliance with the facility's policy. The policy mandates that any allegations of misappropriation must be reported to the Administrator and the state health department within 24 hours of being known to a staff member. The Director of Nursing confirmed that the Unit Manager should have reported the missing ring immediately, which would have allowed the facility to comply with the reporting requirements.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that call lights were accessible to residents, affecting two residents who were observed in their rooms. Resident #35, who was admitted with diagnoses including dementia, osteoarthritis, aphasia, and anxiety, was found with a call light that was not within reach. The call light was hung behind the headboard over a wall clock, approximately six feet from the ground. A Registered Nurse confirmed that the call light was out of reach and should have been accessible to the resident while in bed. Similarly, Resident #54, who had multiple diagnoses including Alzheimer's disease, dementia, and diabetes, was also found with an inaccessible call light. The call light was located on the floor under the footboard side of the bed, requiring staff to climb around the bed to retrieve it. The Registered Nurse confirmed that the call light should always be within reach of the resident while in bed. Interviews with the Administrator and Director of Nursing revealed uncertainty about the existence of a facility policy regarding call light accessibility, and no policy was provided.
Unqualified Activity Director in Place
Penalty
Summary
The facility failed to ensure that a qualified Activity Director (AD) was in place to oversee the activity services for all 99 residents. The personnel file review revealed that the current AD, who was initially hired as a part-time activities aide, did not meet the qualifications required for the position. The AD had a high school diploma and some college experience but did not graduate. She was promoted to Activities Manager despite lacking the necessary certification, an associate degree in recreation, or two years of full-time experience as an activities aide, as stipulated in the facility's job description for the position. Interviews with the AD and the Human Resources Director (HRD) confirmed that the AD had only six months of full-time experience and no supervisory experience. The HRD acknowledged that the AD did not meet the criteria for the role, as she lacked the required educational background and certification. The AD relied on online resources for planning activities and confirmed that there was no regional or corporate oversight for the activities program. This deficiency had the potential to affect all residents in the facility.
Medication Management and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, as well as securing medication carts when not in use. During observations, two registered nurses were found leaving their medication carts unlocked and unattended while administering medications to residents. This was against the facility's policy, which mandates that medication carts must be locked when out of sight or unattended. Additionally, the facility did not adhere to proper labeling practices for medications, as evidenced by the lack of an opening date on a vial of Cosopt ophthalmic solution for a resident with Alzheimer's disease, glaucoma, and osteoarthritis. The medication had been administered without knowing when it should be discarded, contrary to the manufacturer's guidelines that specify a 28-day usage period after opening. Further deficiencies were noted in the medication storage practices within the facility. An open, undated vial of tuberculin testing solution and a vial of influenza vaccine were improperly stored in a medication room refrigerator. The influenza vaccine was found inside a tuberculin testing solution box, which could lead to medication errors. The manufacturer's guidelines for the tuberculin testing solution require that vials be discarded after 30 days of opening to prevent degradation, a practice not followed by the facility. These lapses in medication management had the potential to affect all residents in the facility, which had a census of 99 residents.
Deficiencies in Kitchen Equipment Maintenance and Food Safety Practices
Penalty
Summary
The facility failed to prevent contamination of clean equipment and utensils, maintain kitchen equipment in proper working condition, and adhere to datemarking procedures. Observations revealed chipped paint on a ceiling door above a storage rack for clean pots and pans, posing a risk of contamination. The Dietary Director confirmed the potential for paint chips to fall onto the clean items. Additionally, a leak from the garbage disposal was noted, with pooling liquid on the dish room floor, which had been an issue for approximately two months without a work order being filed for repair. Further deficiencies were observed in the facility's datemarking practices. Bags of cheese and a log of bologna in the walk-in cooler were found to be past their hold time or undated, contrary to the facility's policy of marking food for disposal within seven days. The Dietary Director confirmed these items should have been discarded. Similarly, mushrooms in the cooler were out of date, indicating a failure to follow the datemarking policy. The facility also failed to maintain kitchen equipment, as evidenced by a noncommercial microwave with peeling metal and a reach-in cooler with pooling water. Despite daily monitoring by kitchen staff, no work orders were submitted for these issues. The local health department had advised the facility to replace the microwave with a commercial-grade unit, but this had not been done. The pooling water in the reach-in cooler was a recurring problem, yet no maintenance requests were documented.
Incomplete Facility Assessment Documentation
Penalty
Summary
The facility failed to ensure that their facility-wide assessment contained all required information, which had the potential to affect all residents residing in the facility. The assessment, updated on 08/19/24, was incomplete in several critical areas. Specifically, the sections regarding ethnic, cultural, or religious factors that could affect resident care, contracts and agreements with third parties for services or equipment, health information technology resources, and facility-based and community-based risk assessments were left blank. This lack of comprehensive assessment documentation was confirmed during a review of the facility's records. Interviews conducted on 08/26/24 with the Administrator and the Director of Nursing (DON) further confirmed the deficiencies in the facility assessment. The DON acknowledged that the facility had residents whose primary language was not English, including two who spoke French Creole, one who spoke another language, and one who spoke Vietnamese. Despite these language needs, the relevant section in the assessment was not completed. Additionally, the DON noted that the facility's Quality Assurance/Performance Improvement (QAPI) meeting was held on the same day, but the members did not have time to review the assessment thoroughly, leaving the deficiencies unaddressed.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for several residents, as observed during an annual survey. Resident #44's room was found to be filthy, with a sticky floor and soiled bedspread, and stained walls. These conditions were confirmed by the Maintenance Director and Housekeeping Supervisor. Similarly, Resident #78's room had a sticky floor, dried residue on the bathroom floor, and shredded rubber pellets scattered on the floor, which were also verified by the facility staff. Other residents, including #26, #90, #35, #92, and #18, were found to have rooms that were not in a homelike condition. These rooms had scuffed walls, drywall patches, and lacked personal items or decorations, making them appear bare and uninviting. The Maintenance Director, Housekeeping Supervisor, and Activity Supervisor confirmed these observations, noting the absence of items that would contribute to a homelike environment, such as clocks and dressers. The facility's Routine Cleaning and Disinfection Policy and Quality of Life-Homelike Environment policy were reviewed, indicating a commitment to providing a safe, clean, and comfortable environment. However, the observations and interviews during the survey revealed a failure to adhere to these policies, resulting in an environment that did not meet the standards of cleanliness and homeliness expected in a long-term care setting.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 12.9% error rate. This deficiency affected four residents, each with specific medication administration issues. Resident #64 did not receive their prescribed dose of Namenda due to its unavailability, despite the presence of an emergency supply. The LPN responsible did not notify the Director of Nursing and failed to utilize the emergency supply, leading to a missed dose. Resident #27 was prescribed Zoloft 150 mg but only received 100 mg due to a shortage of the required dosage in the medication cart. The RN administering the medication was unable to find the correct dosage in the emergency supply and proceeded to give a partial dose. This was confirmed by the Unit Manager, who noted that the missing medication had been ordered but would not arrive until later. Resident #08 received the wrong laxative, Senna 8.6 mg instead of the prescribed Senna-S, due to the RN's assumption that the available medication was close enough to the ordered one. Additionally, Resident #49's insulin administration was compromised as the RN failed to prime the insulin pen, contrary to the manufacturer's instructions. These errors were not in line with the facility's policies on medication administration and error reporting.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure that residents with physician's orders for enhanced barrier precautions (EBP) had appropriate signage and personal protective equipment (PPE) available outside their rooms. This deficiency affected three residents who were identified to be on EBP due to open wounds. Observations revealed that there were no signs indicating EBP on the doors of these residents, nor were there containers of PPE available outside their rooms. Interviews with staff confirmed the absence of necessary signage and PPE, which was against the facility's policy requiring such precautions. Additionally, the facility did not adhere to proper infection control practices during wound care for a resident. An LPN was observed using the same scissors to cut both the soiled dressing and the new dressing without cleaning them in between. The LPN also touched the tip of a cream container directly to the resident's open wound and failed to perform hand hygiene between glove changes. This was in violation of the facility's policy, which mandates hand hygiene before and after contact with residents and between glove changes. The facility also failed to ensure proper glove use and hand hygiene in other instances. A nursing assistant was observed exiting a resident's room wearing gloves, touching her hair and face, and using her phone before entering another resident's room and the nurses' station without changing gloves. Furthermore, an RN administered insulin to a resident without wearing gloves, contrary to the facility's policy that requires gloves to be worn during such procedures. Interviews with staff confirmed these lapses in infection control practices.
Failure to Manage Resident's Financial Affairs
Penalty
Summary
The facility failed to manage a resident's financial affairs properly, specifically regarding the payment of a life insurance policy. The resident, who was admitted with diagnoses including dementia and Alzheimer's disease, was unable to make daily care decisions due to poor cognition and memory. The resident's life insurance policy, which had been managed by the family since 2002, was transferred to the facility's business office manager in May 2023. The facility was responsible for making quarterly payments starting in July 2023. However, the facility did not make the scheduled payment in April 2024, resulting in the cancellation of the life insurance policy by the insurance company. The business office manager confirmed the oversight and acknowledged that a double payment was made in June 2024 in an attempt to reinstate the policy, but it had not been reinstated at the time of the report. The facility's policy on abuse, mistreatment, neglect, exploitation, and misappropriation of resident property emphasizes the importance of preventing such issues, yet the failure to make the insurance payment led to a deficiency in managing the resident's financial affairs.
Failure to Timely Notify Physician of Abnormal Lab Results
Penalty
Summary
The facility failed to ensure timely notification of a resident's physician regarding abnormal lab results. Resident #72, who was cognitively intact and had diagnoses including Alzheimer's disease, venous insufficiency, and an open wound on the left lower leg, was affected by this deficiency. A physician's order was placed to obtain a culture of the wound, which was done on 08/21/24. The results, received on 08/24/24, indicated a heavy growth of streptococcus pyogenes, which required antibiotic treatment. Despite the availability of these results, the nurse progress notes from 08/24/24 to 08/26/24 did not document any notification to the physician. It was confirmed through an interview with LPN #215 that the physician was only notified on 08/26/24, two days after the results were received. This delay was not in accordance with the facility's policy, which mandates immediate notification of significant changes in a resident's condition to the physician and family members.
Communication and Personal Hygiene Deficiencies in LTC Facility
Penalty
Summary
The facility failed to effectively communicate with a resident who primarily spoke French Creole and had medical conditions including dementia, depression, aphasia, and a history of stroke. Despite the resident's care plan indicating the need for an interpreter and alternative communication methods such as a communication board, staff interviews and observations revealed that these interventions were not utilized. Staff members, including registered nurses and licensed practical nurses, admitted to guessing the resident's needs due to the language barrier and lack of communication tools. The facility's assessment did not address ethnic, cultural, or personal preferences that could affect care, and there was no evidence of attempts to use alternative communication means in the resident's progress notes. Another resident, who had medical conditions such as dementia, COPD, rheumatoid arthritis, and congestive heart failure, was observed with unkempt hair over several days. Despite the resident's care plan indicating the need for assistance with activities of daily living, including personal hygiene, staff failed to provide necessary hair care. An RN confirmed the resident's hair was unkempt and noted that the resident complied when asked to have her hair fixed, indicating a lack of proactive care from the staff. The facility's policy on supporting activities of daily living, which includes providing appropriate care and services for residents unable to carry out ADLs independently, was not adhered to in these cases. The policy emphasized interventions in accordance with assessed needs and preferences, yet the facility did not implement the necessary support for communication and personal hygiene as outlined in the residents' care plans.
Failure to Meet Residents' Activity Needs
Penalty
Summary
The facility failed to provide activities that met the needs and preferences of several residents, as evidenced by the experiences of three residents. Resident #27, who has dementia and moderately impaired cognition, expressed dissatisfaction with the lack of activities and opportunities to go outside. Despite having interests in music, outdoor activities, and religious services, the resident's activity participation logs showed minimal engagement in these areas. Interviews with staff revealed a lack of awareness of the resident's preferences and a failure to invite the resident to activities, contributing to the resident's feelings of unhappiness and isolation. Resident #72, with intact cognition and a history of Alzheimer's disease, also reported insufficient activities and restrictions on movement within the facility. The resident expressed a desire for exercise and outdoor activities but was often told to return to his room when attempting to engage in such activities independently. The activity participation logs for this resident showed limited involvement in preferred activities, and staff interviews indicated a lack of knowledge about the resident's interests and a failure to invite him to participate in activities. Resident #45, who is severely cognitively impaired and dependent on staff for activities, experienced gaps in activity participation, particularly at the end of each month. Despite having preferences for music and outdoor activities, the resident was not consistently engaged in these activities. Staff interviews revealed staffing shortages and a lack of structured activity offerings, particularly in the afternoons and evenings. The resident's activity sheets showed blank weeks, indicating a lack of engagement during those periods, and the resident was not invited to participate in a scheduled nature walk, further highlighting the deficiency in meeting the resident's activity needs.
Failure to Follow Physician Orders for Daily Weights
Penalty
Summary
The facility failed to adhere to physician orders regarding the daily weighing of a resident, which was crucial for monitoring her congestive heart failure. The resident, who had Alzheimer's disease with agitation, congestive heart failure, psychotic disorder with delusions, and paranoid schizophrenia, was admitted to the facility with a care plan that included daily weight monitoring. The physician's order specified that the resident should be weighed daily at 6:00 A.M., with any significant weight gain reported immediately. However, the medical record review revealed that weights were not documented on three specific dates. An interview with the Unit Manager confirmed that the weights were not obtained and documented as ordered.
Failure to Assist Resident with Corrective Lenses
Penalty
Summary
The facility failed to assist Resident #78 with applying his corrective lenses, which was necessary for his visual acuity. Resident #78, who has a medical history of dementia, polyneuropathy, and hemiplegia following a stroke, was assessed to have myopic astigmatism and presbyopia, requiring new bifocals for full-time use. Despite receiving new glasses, observations revealed that Resident #78 was frequently not wearing them, and they were often found on top of a tall wardrobe, out of his reach. Multiple observations over several days showed Resident #78 without his glasses, both in his room and in common areas like the dining room. Interviews with staff, including a State Tested Nurse Aide (STNA) and the Activity Director, indicated a lack of awareness or action regarding the resident's need for glasses. On several occasions, staff had to retrieve the glasses from the wardrobe and assist Resident #78 in wearing them, after which he expressed improved vision. The facility's policy on Supporting Activities of Daily Living (ADLs) states that residents should be provided with appropriate care and assistance in accordance with their care plan. However, the repeated failure to ensure Resident #78 wore his glasses as needed suggests a deficiency in adhering to this policy, impacting his ability to see clearly and navigate the facility safely.
Failure to Maintain Pressure Ulcer Interventions
Penalty
Summary
The facility failed to maintain interventions to promote healing of pressure ulcers for three residents. Resident #18, who had a Stage II pressure ulcer and was supposed to have a pressure-reducing cushion in her chair, was observed multiple times without the cushion. This was confirmed by Unit Manager #227, indicating a failure to follow the physician's orders and care plan. Resident #90, who was at risk for impaired skin integrity, had physician's orders for heel elevators to be used while in bed. However, observations revealed that the heel elevators were not in place during multiple checks. Unit Manager #227 confirmed the absence of the heel elevators, showing a lack of adherence to the prescribed preventive measures. Resident #01, who had an unstageable pressure ulcer and was receiving hospice services, was supposed to have an alternating pressure mattress as per physician's orders. However, observations and interviews revealed that the mattress was set on static or pulsate settings instead of the required alternate setting. Both RN #190 and LPN UM #215 were unaware of the correct settings, indicating a lack of knowledge and training regarding the equipment used for pressure ulcer prevention and treatment.
Failure to Administer Tube Feeding as Ordered
Penalty
Summary
The facility failed to administer tube feedings at the rate ordered by the physician for a resident with multiple medical conditions, including dementia with agitation, dysphagia, severe protein calorie malnutrition, and diabetes. The resident was cognitively impaired and had a physician's order for Isosource 1.5 to be administered via gastrostomy tube at 55 cc per hour continuously. However, observations on two separate occasions revealed that the resident was receiving Jevity 1.5 at 50 cc per hour instead. This discrepancy was confirmed by the Unit Manager, indicating a failure to follow the physician's specific orders for the resident's nutritional needs.
Insulin Administration Error
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors related to insulin administration. Specifically, Resident #49, who was cognitively impaired and had a diagnosis of type two diabetes, received insulin injections outside the parameters specified in the physician's order. The physician's order for Resident #49 required Humalog insulin to be administered only if the blood glucose level was 140 mg/dl or higher. However, the Medication Administration Record (MAR) indicated that the resident received insulin on multiple occasions when the blood glucose level was below the specified threshold. The Director of Nursing (DON) confirmed that the insulin was administered outside the parameters on several dates in August 2024. The facility's policy on medication administration required nurses to verify each medication to ensure it was the right drug, dose, route, rate, time, and for the right customer, and to ensure the MAR reflected the most recent medication order. Despite this policy, the insulin was administered incorrectly, indicating a failure to adhere to the established guidelines.
Lack of Transfer Agreements with Hospitals
Penalty
Summary
The facility failed to ensure that transfer agreements with hospitals certified by Medicare or Medicaid were in place, which had the potential to affect all 99 residents residing in the facility. A review of the facility's 2024 Tabletop Disaster Drill document revealed that the facility had agreements to transfer residents to two sister facilities in the event of an emergency. However, it was confirmed through interviews with the Director of Nursing and the Administrator that a written transfer agreement was not executed until August 26, 2024. Prior to this date, the facility did not have a transfer agreement in place, which was a requirement to ensure residents could be moved quickly to a hospital when they needed medical care.
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.
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What surveyors actually found near you
We read the 844 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — 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) |
|---|---|---|---|---|
| Sapphire Rehabilitation And Care Center | 1.3 mi | ★★★★★ | 18 | 1 |
| Wesley Glen Health Services Corp | 1.4 mi | ★★★★★ | 1 | 0 |
| Riverview | 1.5 mi | ★★★★★ | 0 | 0 |
| Crown Pointe Care Center | 1.7 mi | ★★★★★ | 1 | 0 |
| Laurels Of Worthington, The | 2.9 mi | ★★★★★ | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.