Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Majestic Care Of Columbus Llc during CMS and state inspections, most recent first.
A resident with severe cognitive impairment had conflicting advance directive information across the paper chart, code status book, and EHR. The EHR banner and order showed FULL CODE with DNR-CC pending POA signature, while the paper record contained a signed DNR-CC form and a PA note documented guardian approval for the code status change. Staff stated they relied on the EHR banner to determine code status, and the DON confirmed the mismatch.
Failure to timely report abuse allegation: A resident with dementia, MS, epilepsy, bipolar disorder, and depression had a verbal altercation with a CNA in which profanity was used in front of the resident. Multiple staff witnessed the incident, the resident confirmed the profanity, and the regional nurse consultant acknowledged the allegation was not reported to the State Agency within the required timeframe.
Incomplete Investigation of Alleged Verbal Abuse: A resident with dementia, MS, epilepsy, bipolar disorder, and depression was involved in a verbal altercation with a CNA in which profanity was used. The incident was reportedly witnessed by multiple staff, but the investigation file did not include a statement from one CNA, and the RN who completed the SRI confirmed that no statement was obtained from that staff member despite facility policy requiring interviews of anyone who witnessed or heard the incident.
A resident with dementia, MS, bipolar disorder, and depression was involved in a verbal altercation with a CNA at the nurses' station. The CNA refused to assist with toileting and ostomy care, called the resident a liar, and used profanity multiple times in the resident's presence; multiple staff witnesses confirmed the yelling and profanity in a common area, and the resident said the language in her home offended her.
The facility did not notify two residents, one with cognitive impairment and one cognitively intact, when their personal fund balances were within $200 of the SSI resource limit for multiple months. Documentation and interviews confirmed that required notifications to the residents or their representatives were not made.
A resident with a suprapubic catheter did not receive appropriate care and services during routine catheter care, as staff failed to maintain proper technique and dignity. The resident was left fully exposed during the procedure, and the catheter was not properly secured, resulting in tension on the tubing. Staff interviews confirmed that correct practices for securing the catheter and maintaining resident coverage were not followed.
A resident with multiple medical conditions and at risk for skin breakdown did not consistently have ordered heel protectors in place, as required for wound prevention. Despite documentation in the medical record indicating the devices were used, observations showed the resident was often without them, and staff interviews revealed documentation was completed without verification. No refusals were documented, contrary to facility policy.
Surveyors found that two residents with chronic pain did not receive safe, appropriate pain management due to administration of PRN pain medication without proper pain assessment, lack of documentation of nonpharmacological interventions, and failure to evaluate and document the effectiveness of pain medications after administration, contrary to facility policy and care plans.
Staff failed to implement proper infection control practices during suprapubic catheter care for a resident with multiple medical conditions. A CNA, assisted by nursing staff, placed soiled washcloths back into clean soapy water and reused the contaminated water for cleansing the catheter site, contrary to facility protocols. Interviews confirmed that this practice occurred and was not in line with infection prevention standards.
A resident with dementia and a history of falls experienced two unwitnessed falls in one day, resulting in head trauma and hospitalization. Despite existing interventions, the facility failed to implement timely and effective measures to prevent further falls. Neurological checks revealed a change in the resident's condition, but no additional assessments or fall interventions were made. The facility's policy required monitoring and revising interventions, which was not adequately done.
The facility failed to maintain safe and sanitary food storage, affecting all residents. Observations showed expired and undated food items in the kitchen, including expired milk served to a resident. Interviews confirmed the facility's policy was not followed, as food should be dated and expired items discarded.
A resident experienced delays in accessing their personal funds due to the facility's failure to maintain adequate cash reserves in the fund box. Despite a policy allowing for daily cash withdrawals of up to $50, the resident was initially only able to withdraw $10 and had to wait over 48 hours to receive the remaining $20. Staff interviews confirmed that the facility often ran low on cash, requiring trips to the bank to replenish funds.
The facility failed to ensure arbitration agreements were explained in a language residents or their representatives could understand and did not include all required components. This affected several residents, with interviews revealing a lack of understanding and communication regarding the arbitration process. The facility was reviewing the agreements at a corporate level after survey concerns were identified.
A resident with cognitive impairment and a history of eating quickly was not supervised during meals as required by her care plan, leading to a choking incident. Despite needing supervision, she was observed eating alone, and staff confirmed the lack of oversight. The resident expressed dissatisfaction with her prescribed diet, which sometimes led her to skip meals.
The facility failed to timely identify and treat UTIs for two residents, leading to significant delays in care. One resident experienced a 50-day delay in receiving appropriate antibiotics due to contaminated urine samples and lack of follow-up. Another resident's UTI was not treated after a contaminated urinalysis, with no further action taken. These deficiencies highlight issues in managing UTIs, including inadequate communication with the laboratory and delays in obtaining and acting on test results.
The facility failed to ensure physicians provided rationales for declining pharmacy-recommended gradual dose reductions for two residents. One resident with severe cognitive deficits and multiple diagnoses was on Hydroxyzine, and another with moderate cognitive deficits was on Zoloft. In both cases, the physician declined the pharmacist's recommendations without providing a rationale, as confirmed by the DON.
The facility failed to properly store and label medications, specifically a multi-dose vial of tuberculin skin testing solution, which was found undated and unlabeled in the medication refrigerator. An LPN confirmed the vial was delivered from the pharmacy and should have been labeled according to the facility's policy, which requires opened stock medications to expire 30 days after opening. This affected two residents on the third floor.
The facility failed to justify antibiotic use for two residents, leading to deficiencies in antibiotic stewardship. A resident with multiple diagnoses was placed on Cipro before culture results showed resistance, necessitating a change to Keflex. Another resident with urinary issues experienced delays in obtaining accurate culture results, leading to premature antibiotic prescriptions. The facility's policy on antibiotic stewardship was not followed, resulting in inappropriate antibiotic use.
The facility failed to maintain an adequate emergency water supply, potentially affecting all 74 residents. The emergency water policy lacked details on storage and distribution, and the current supply was insufficient. During an observation, staff struggled to locate the emergency water, which was found to be only 93 gallons, far below the estimated need for three days or a week.
A resident with cognitive intactness and multiple diagnoses was not informed of her discharge plan until shortly before the scheduled transfer, leading to confusion and distress. The facility packed her belongings without her knowledge and attempted to transfer her without adequately informing her of the details. The resident refused to get on the transport bus, resulting in police involvement. The facility's actions led to the resident being left without a clear understanding of her discharge plan, violating the policy for a safe and orderly transfer.
The facility failed to maintain water heater temperatures at the required 140 degrees Fahrenheit, as outlined in its legionella prevention policy. From February to July 2024, water heater tanks #1 and #2 consistently recorded temperatures between 110-112 degrees Fahrenheit. Interviews and observations confirmed the facility's non-compliance with its water management program, which is based on CDC and ASHRAE guidelines, potentially affecting all residents.
The facility failed to update PASRR assessments accurately and timely for several residents, missing diagnoses such as Alzheimer's, dementia, and mood disorders. The Social Services Director did not adhere to the policy requiring prompt referral for Level II reviews upon changes in residents' mental health conditions.
The facility failed to maintain a clean and safe environment for residents, with issues such as persistent urine odor, dried blood stains, and damaged infrastructure in resident rooms. Despite some residents refusing housekeeping services, the facility did not address these issues promptly, leading to unsanitary and unsafe conditions.
A facility failed to complete a PASRR for a resident who remained over 30 days. The resident had multiple diagnoses and was initially exempted from PASRR due to no mental disorder diagnosis. However, the facility did not complete the required screening after the exemption expired. Staff interviews confirmed the oversight, and no documentation was found to show compliance with the facility's policy on PASRR completion.
A resident with multiple medical conditions developed a pressure wound that was not managed properly by the facility. The wound care nurse practitioner's treatment orders were delayed, and there were discrepancies in physician documentation. The resident's wound worsened over time, with assessments showing changes in size and depth, and the facility failed to consistently follow recommended treatment protocols.
A resident with a complex medical history experienced inadequate pain management due to the facility's failure to administer prescribed medications consistently and assess their effectiveness. Despite reporting moderate to severe pain, the resident did not receive appropriate pain relief, leading to hospitalization for severe abdominal pain and other complications. Interviews confirmed the facility's lack of regular monitoring and assessment of the resident's pain levels.
A resident with cognitive impairment and a history of incontinence was inappropriately prescribed Macrobid for a UTI without a confirmed diagnosis. Hospital records showed no UTI, and symptoms were due to hypoglycemia and orthostatic hypotension. The DON confirmed the lack of evidence for the UTI diagnosis, indicating a failure in the facility's antibiotic stewardship program.
Advance Directive Code Status Mismatch
Penalty
Summary
The facility failed to ensure a resident's advance directives matched in the paper chart and electronic health record. Resident #7 had diagnoses including Alzheimer's disease with late onset, dementia with mood disturbance, paranoid schizophrenia, and severe protein-calorie malnutrition, and the quarterly MDS showed a BIMS score of 5 out of 15, indicating severe cognitive impairment. The record contained conflicting code status information: an order and the electronic banner stated the resident was FULL CODE with DNR-CC pending a POA signature, while the paper chart and code status book contained a signed DNR form indicating DNR-CC. A progress note documented that a PA spoke with the resident's guardian about the code status change and that approval was given for DNR-CC, with paperwork completed and sent for order change and document upload. During interviews, an LPN and the DON stated staff relied on the electronic banner to determine code status, and the DON confirmed the code status book contained the signed DNR-CC form but was not aware of it at the time. The DON also confirmed the code status in the electronic record did not match the order and banner until it was later changed to DNR-CC.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to ensure an allegation of abuse was timely reported to the State Agency. Resident #23, who was admitted with diagnoses including dementia, encephalopathy, epilepsy, multiple sclerosis, bipolar disorder, and major depressive disorders, had a comprehensive MDS assessment showing intact cognition with a BIMS score of 15 and required self-care assistance due to impaired physical mobility related to multiple sclerosis. A facility self-reported incident documented an emotional/verbal abuse allegation involving CNA #94 and Resident #23 after a verbal altercation in which profanity was used in front of the resident, and the incident was witnessed by multiple staff members. Resident #23 confirmed that CNA #94 used profanity multiple times in front of her. CNA #74 stated she reported the incident to human resources and that the Regional Nurse Consultant was contacted the same morning. The Regional Nurse Consultant confirmed she was informed of the incident on 11/27/25, but did not open the SRI until 11/30/25 because it was her first day back in the office, and she confirmed the incident was not timely reported to the State Agency. The facility policy required the administrator or designee to notify the Department of Health not later than two hours after an allegation of abuse is made.
Incomplete Investigation of Alleged Verbal Abuse
Penalty
Summary
The facility failed to complete a thorough investigation after a potential abuse incident involving Resident #23 and CNA #94. Resident #23 was admitted with diagnoses including dementia, encephalopathy, epilepsy, multiple sclerosis, bipolar disorder, and major depressive disorders, and the resident's comprehensive MDS assessment documented intact cognition with a BIMS score of 15 and a need for self-care assistance related to impaired physical mobility from multiple sclerosis. A facility SRI for emotional/verbal abuse stated that on 11/27/25 at 7:00 A.M., CNA #94 and Resident #23 had a verbal altercation in which profanity was used, and the incident was witnessed by CNA #59, CNA #113, CNA #74, and RN #133. Review of the investigation documentation showed that it did not contain a statement from CNA #113. During interview, CNA #113 stated she did not witness the alleged incident between CNA #94 and Resident #23. The Regional Nurse Consultant, who initiated the SRI and completed the investigation, confirmed that she did not obtain a statement from CNA #113. The facility policy Abuse, Mistreatment, Neglect, Exploitation and Misappropriation stated that the person investigating the incident should interview anyone who witnessed or heard the incident.
Resident Subjected to Verbal Altercation and Profanity
Penalty
Summary
The facility failed to ensure a resident was treated with respect and dignity. Resident #23 was admitted with diagnoses including dementia, encephalopathy, epilepsy, multiple sclerosis, bipolar disorder, and major depressive disorders, and the comprehensive MDS assessment documented intact cognition with a BIMS score of 15. The resident required self-care assistance because of impaired physical mobility related to multiple sclerosis. A facility SRI documented that on 11/27/25 at 7:00 A.M., CNA #94 had a verbal altercation with Resident #23 at the nurses' station. During the incident, CNA #94 refused to assist the resident with toileting and ostomy care, called the resident a liar, and used profanity multiple times in the resident's presence. The altercation was witnessed by CNA #59, CNA #113, CNA #74, and RN #133, all of whom confirmed that CNA #94 was yelling and using profanity in a resident common area while Resident #23 was present. Resident #23 later stated that the language used in her home offended her.
Failure to Notify Residents of Personal Fund Balances Near SSI Resource Limit
Penalty
Summary
The facility failed to notify residents who received Medicaid benefits when their personal fund balances reached within $200 of the Social Security Income (SSI) resource limit, as required. For one resident with significant cognitive impairment and multiple complex medical diagnoses, records showed that their account balance was within $200 of the SSI resource limit for five consecutive months. There was no documented evidence that the resident or their representative was notified of this status during that period. The resident's care plan noted communication problems and cognitive deficits, further emphasizing the importance of proper notification. A second resident, who was cognitively intact and had a history of multiple chronic conditions, also had personal funds within $200 of the SSI resource limit for three months. Again, there was no documentation that the resident or their representative was notified. The Business Office Manager confirmed in an interview that notifications were not sent to either resident or their representatives during the relevant months.
Failure to Maintain Dignity and Proper Technique During Suprapubic Catheter Care
Penalty
Summary
During routine suprapubic catheter care for a resident with a history of obstructive and reflux uropathy, major depressive disorder, insomnia, chronic pain syndrome, and prior cerebrovascular events, staff failed to follow proper technique and maintain the resident's dignity. The care plan and physician orders required cleansing the suprapubic site every shift with soap and water, covering with split gauze, and maintaining infection control practices. However, observation revealed that the resident was left fully exposed throughout the procedure, with the brief around the knees, and was not covered to maintain dignity. The resident was positioned flat in a Trendelenburg position, and the catheter care was performed by a CNA, assisted by the ADON and an RN. During the procedure, the CNA cleansed the catheter insertion site using a washcloth dipped in soapy water, holding the catheter approximately three inches below the insertion point, which caused tension on the catheter tubing. The same process was repeated with rinse water. Interviews with the ADON, CNA, and RN confirmed that the catheter was not properly secured at the insertion point, resulting in tugging on the tubing, and that the resident should have been kept covered except during the actual peri-care. The staff acknowledged that proper technique and dignity were not maintained during the catheter care.
Failure to Ensure Use of Ordered Pressure Reducing Devices
Penalty
Summary
The facility failed to ensure that pressure reducing devices were in place as ordered for a resident at risk for skin breakdown. The resident, who had multiple diagnoses including cerebral atherosclerosis, dementia, and moderate protein calorie malnutrition, was cognitively intact and had no active wounds. Physician orders required the use of bilateral heel protectors when in bed for wound prevention. The care plan noted the resident sometimes refused preventative boots and floating heels, but there was no documentation of refusal in the behavior logs for the period reviewed. The Treatment Administration Record (TAR) indicated the boots were in place as ordered, but direct observations on multiple occasions showed the resident either had only one boot on, had no boots on, or was not offloading his heels as required. Interviews with staff revealed that Certified Nursing Aides did not document refusals and would report them to a nurse, who was responsible for documentation. However, the nurse confirmed that documentation was completed without verifying whether the boots were actually in use, and that no refusals were documented in the behavior logs. The facility's wound management policy required timely recognition and intervention for impaired skin integrity, but the lack of accurate documentation and failure to ensure the use of ordered pressure reducing devices constituted a deficiency in care.
Failure to Provide and Document Safe, Appropriate Pain Management
Penalty
Summary
Surveyors identified deficiencies in the facility's pain management practices for multiple residents with chronic pain and complex medical histories. For one resident with diagnoses including bipolar disorder, emphysema, spinal stenosis, and chronic pain, the medical record showed that as-needed (PRN) pain medication was administered even when the resident reported a pain level of zero. Documentation was incomplete, with missing descriptions of pain and lack of evidence that nonpharmacological interventions were attempted prior to medication administration, as required by the care plan and facility policy. The Director of Nursing confirmed that PRN pain medications should not be given for a pain level of zero and that documentation of nonpharmacological interventions and pain descriptions was expected with each administration. Another resident with chronic pain syndrome, diabetes with polyneuropathy, and other comorbidities was receiving scheduled and PRN pain medications. The care plan required evaluation of the effectiveness of pain interventions and documentation of resident satisfaction and impact on function. However, the Medication Administration Record showed that while pain levels were recorded at the time of medication administration, there was no follow-up documentation evaluating the effectiveness of the pain medication. Interviews with staff confirmed that effectiveness was not routinely assessed after administration, and there was no established pain goal for the resident. Facility policy required documentation of the reasons for administration and the effectiveness of pain medications in the medical record, as well as monitoring and physician notification as needed. The survey found that these requirements were not consistently met for the residents reviewed, resulting in a failure to provide safe, appropriate, and well-documented pain management services.
Failure to Follow Infection Control Practices During Catheter Care
Penalty
Summary
During routine suprapubic catheter care for a resident with a history of obstructive and reflux uropathy, major depressive disorder, insomnia, chronic pain syndrome, and prior cerebrovascular events, staff failed to follow proper infection control practices. The resident, who was cognitively intact and dependent on staff for toileting, had physician orders and care plan interventions specifying catheter site cleansing every shift with soap and water, use of split gauze, and documentation of output. During the observed procedure, a CNA, assisted by the ADON and an RN, placed soiled washcloths back into containers of clean soapy water and reused the contaminated water for further cleansing of the catheter site. The resident was also left exposed during the procedure, and a blanket with visible hairs was used to cover the resident afterward. Interviews with the ADON, CNA, and RN confirmed that soiled washcloths should not have been placed back into clean water basins, and that this practice contaminated the water used for catheter care. The CNA acknowledged the error but was unsure if it occurred during the observed procedure, while the RN confirmed witnessing the contamination. These actions were inconsistent with established infection control protocols and the facility's own policies for catheter care.
Failure to Implement Effective Fall Management Program
Penalty
Summary
The facility failed to implement a comprehensive and individualized fall management program for a resident with a history of falls and multiple medical conditions, including dementia and epilepsy. The resident experienced two unwitnessed falls on the same day, resulting in head trauma and hospitalization. The first fall occurred when the resident attempted to change a colostomy bag without assistance, despite being known to resist help with such tasks. Although interventions like Dycem, skid strips, and bilateral falls mats were in place, the facility did not implement timely and effective measures to prevent further falls. After the first fall, the facility added a sign in the resident's room to remind them to call for assistance, but there was no evidence that 15-minute checks, which were supposed to be conducted, were completed. Neurological checks were performed post-fall, revealing a change in the resident's level of consciousness from fully conscious to lethargic. However, there were no additional assessments or changes to the resident's fall interventions in response to this change in condition. The second fall occurred later that day, with the resident found beside the bed with a head injury. Despite the resident's lethargy and confusion noted earlier, no new fall risk or safety interventions were implemented before this fall. The facility's Director of Nursing confirmed that the neurological checks were not documented in the electronic medical record and that there were no additional progress notes or assessments following the change in the resident's condition. The facility's policy required that interventions be monitored for effectiveness and revised as needed, but this was not adequately done in this case.
Deficiency in Food Storage and Expiration Management
Penalty
Summary
The facility failed to ensure the safe and sanitary storage of food and drink items in the kitchen, which had the potential to affect all 74 residents. Observations revealed that a resident consumed chocolate milk from a breakfast tray that was past its use-by date. In the facility kitchen, several food items in the freezer and refrigerator were found to be unlabeled, undated, and in some cases, open to air. This included fish, green beans, chicken fingers, chocolate chip cookie dough, mustard, Worcestershire sauce, an unknown brown juice, cinnamon apples, and baby carrots. Additionally, a significant number of chocolate milk containers in the walk-in refrigerator were expired and had been served during breakfast service. Interviews with the Kitchen Manager and Regional Kitchen Manager confirmed that all food should be dated when opened and marked with a use-by date, and expired food should not be served. The Regional Kitchen Manager also confirmed that expired milk had been served and that yogurt with an expired use-by date was found on trays for lunch service. The facility's policy on cold foods stated that food should be stored in wrapped or covered containers, labeled, and dated, which was not adhered to in these instances.
Failure to Provide Timely Access to Resident Funds
Penalty
Summary
The facility failed to ensure that residents' personal funds were available in a timely manner, affecting one resident directly and potentially impacting 68 others. A resident reported difficulty accessing $30 from their personal fund account, being told they could only receive $10 initially and would need to return for the remaining $20. Despite repeated requests, the resident did not receive the additional $20 until over 48 hours later. Observations and interviews with staff confirmed that the facility's fund box was inadequately stocked, with only $38 available at one point, despite a policy to maintain $1,000 for resident withdrawals. Further investigation revealed that the facility's fund box was frequently understocked, leading to delays in fulfilling residents' requests for their funds. Staff interviews indicated that the facility sometimes ran low on cash after residents withdrew money at the beginning of the month, and staff had to go to the bank to replenish the fund box. The Business Office Manager acknowledged the delay in providing the requested funds to the resident and confirmed that the facility's policy allowed for cash withdrawals of up to $50 per day, which was not adhered to in this instance.
Failure to Explain Arbitration Agreements
Penalty
Summary
The facility failed to ensure that arbitration agreements were thoroughly explained to residents or their representatives in a language they could understand. Additionally, the facility did not include all required components and information in the arbitration agreements. This deficiency affected three residents and had the potential to affect 23 additional residents who were admitted to the facility since a specified date. During interviews, it was revealed that the facility did not have arbitration agreements in place, and the admissions staff confirmed that the facility no longer provided these agreements for resident review. However, it was acknowledged that any agreements already made or signed would still be honored. The review of the arbitration agreement showed that it lacked language stating that the agreement was not required and not a condition of admission. Interviews with the Administrator and admissions staff revealed a lack of understanding and communication regarding the arbitration process at the facility. The Administrator acknowledged that the arbitration agreement documents should be thoroughly explained and confirmed that specific language should be included in the agreement as per regulation. The facility was in the process of reviewing the arbitration agreements at a corporate level, but it had not been prioritized until the survey identified concerns. Interviews with the affected residents revealed that they were not familiar with the arbitration agreement and could not recall if they had been provided or signed one upon admission.
Failure to Supervise Resident During Meals
Penalty
Summary
The facility failed to provide necessary supervision to a resident, identified as Resident #13, during meals, as outlined in the resident's care plan. Resident #13, who has a complex medical history including cognitive impairment, epilepsy, and vascular dementia, was noted to require supervision while eating due to a tendency to eat quickly, which increased the risk of choking. Despite this requirement, the resident was observed eating unsupervised in her room, which led to an incident where she choked on her food, became unresponsive, and required emergency medical intervention, including the Heimlich maneuver and CPR, before being transported to the hospital. Interviews and observations revealed that the resident often ate unsupervised, both in her room and in the dining room, contrary to the care plan's directive for supervision. The resident expressed dissatisfaction with the mechanical soft diet prescribed after the choking incident, which she stated led her to sometimes skip meals. Staff interviews confirmed the lack of supervision during meals, and the facility's policy on meal supervision and assistance was not adhered to, resulting in the failure to ensure the resident's safety during meal times.
Failure to Timely Identify and Treat UTIs in Residents
Penalty
Summary
The facility failed to timely identify and treat urinary tract infections (UTIs) for two residents, leading to significant delays in appropriate care. Resident #72, who was cognitively intact and had a Foley catheter, experienced a series of issues with urine samples being contaminated or not processed in a timely manner. Despite initial signs of a UTI, including cloudy urine and blood in the urine, there was a lack of follow-up and communication with the laboratory, resulting in a 50-day delay before appropriate antibiotics were administered. The Interim Director of Nursing acknowledged the delays and attributed them to laboratory issues, but confirmed that the facility did not contact the laboratory during these delays. Resident #59, who had a moderate cognitive deficit and was incontinent of bowel and bladder, was admitted with a prescription for Keflex for infection management. However, upon readmission, the antibiotic was stopped, and a urinalysis was ordered. The urinalysis results indicated probable contamination, but no further action was taken to treat the UTI. The Interim Director of Nursing verified the lack of treatment and follow-up for the contaminated urinalysis. Both cases highlight a failure in the facility's processes for managing UTIs, including inadequate communication with the laboratory and delays in obtaining and acting on test results. These deficiencies affected the timely treatment of UTIs for the residents, potentially impacting their health and well-being.
Failure to Provide Rationale for Declining Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that the physician provided a rationale for declining pharmacy-recommended gradual dose reductions (GDR) for two residents. Resident #31, who has a severe cognitive deficit and multiple diagnoses including Alzheimer's disease, anxiety disorder, and bipolar disorder, was receiving several medications including Hydroxyzine for anxiety. The pharmacist recommended a GDR for Hydroxyzine, but the physician declined without providing a rationale, only indicating that past reduction attempts led to problematic behavior and care challenges. This lack of rationale was confirmed by the Director of Nursing during an interview. Similarly, Resident #59, with a moderate cognitive deficit and diagnoses such as major depressive disorder and vascular dementia, was receiving Zoloft for depression. The pharmacist recommended a GDR for Zoloft, but the physician again declined without providing a rationale. This was also verified by the Director of Nursing. These actions affected two out of five residents reviewed for unnecessary medications, indicating a failure in the facility's process to ensure appropriate medication management and documentation.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, specifically multi-use vials, in accordance with professional principles. During an observation, an LPN identified an opened multi-dose vial of tuberculin skin testing solution in the medication refrigerator on the third floor, which was undated and lacked labeling indicating when it was first accessed or when it would expire. The manufacturer's expiration date was January 2026, but the facility's policy required that opened stock medications expire 30 days after opening. The LPN confirmed that the vial was delivered from the pharmacy on October 22, 2024, and acknowledged the lack of proper labeling. The facility's policy, last revised in April 2019, stated that medications requiring refrigeration should be stored securely and that discontinued or outdated medications should be returned to the pharmacy or destroyed. This deficiency affected two residents admitted to the third floor after November 14, 2024, in a facility with a census of 74.
Inadequate Antibiotic Justification for Two Residents
Penalty
Summary
The facility failed to provide adequate justification for the use of antibiotics for two residents, leading to deficiencies in antibiotic stewardship. Resident #73 was initially admitted with multiple diagnoses, including diabetes, chronic kidney disease, and anxiety disorder. The resident complained of dysuria, and a urinalysis was ordered. Despite abnormal urinalysis results indicating a potential infection, the resident was placed on Cipro before culture and sensitivity (C&S) results were available. The C&S results later revealed resistance to Cipro, necessitating a change to Keflex. The lack of timely follow-up and inappropriate initial antibiotic choice contributed to the deficiency. Resident #72, with a history of chronic obstructive pulmonary disease and urinary issues, experienced similar issues with antibiotic management. The resident's urinary catheter was leaking, and a urinalysis was ordered. However, delays in obtaining and processing the urine samples led to contaminated results. Despite ongoing symptoms, the resident was initially prescribed Levaquin before C&S results were available. Once the results were received, the antibiotic was changed to Macrobid, and later Bactrim was also prescribed. The delay in obtaining accurate C&S results and the premature prescription of antibiotics without proper justification were key factors in the deficiency. The facility's policy on antibiotic stewardship, last revised in 2016, outlines the need for antibiotics to be prescribed under the guidance of the stewardship program. However, the incidents with Residents #73 and #72 demonstrate a failure to adhere to this policy, as antibiotics were prescribed without adequate justification and before obtaining necessary C&S results. This lack of adherence to the policy and the resulting inappropriate antibiotic use highlight the deficiency in the facility's management of antibiotic prescriptions.
Inadequate Emergency Water Supply
Penalty
Summary
The facility failed to ensure an adequate emergency water supply was maintained, which had the potential to affect all 74 residents. The emergency water supply policy lacked provisions for storing potable and non-potable water, methods for distributing water, and details on estimating the needed volume of water. During an interview, the Administrator indicated that the emergency water plan was in the survey readiness binder, which included steps for short-term water shut-offs. However, the contract with the emergency water supplier, WC #1050, stated that water would be provided within 24 to 48 hours, with exceptions if the supplier was also affected by the outage or if fulfilling the contract would endanger their personnel or violate regulations. An observation with the Kitchen Manager revealed that emergency water was not stored in the kitchen, and staff had difficulty locating it. After a search, 93 gallons of water were found in a supply closet, which was less than the 150 gallons typically stored. The Kitchen Manager admitted that the supply was insufficient and could not provide evidence of a recent order for more water. The facility's policy estimated water needs for three days to be between 169.65 to 286.95 gallons, and for a week, between 395.85 to 669.55 gallons, indicating a significant shortfall in the current supply.
Failure to Ensure Orderly Discharge for Resident
Penalty
Summary
The facility failed to ensure an orderly discharge for Resident #79, who was cognitively intact and had been residing in the facility with diagnoses including diabetes, anxiety, delusion disorder, and paranoid schizophrenia. The resident was given a 30-day discharge notice due to safety concerns, which she refused to sign. Despite an appeal hearing that upheld the facility's right to discharge her, the resident was not informed of the final discharge plan until shortly before the scheduled transfer, leading to confusion and distress. The facility made multiple referrals to other skilled nursing facilities, but Resident #79 was not accepted due to behavioral and income issues. On the day of discharge, the facility packed her belongings without her knowledge and attempted to transfer her to another facility without adequately informing her of the details. The resident refused to get on the transport bus as she was not told where she was going, resulting in the police being called to escort her off the property. The facility's actions led to Resident #79 being left without a clear understanding of her discharge plan, and her whereabouts were unknown for a period of time. The facility's policy required a safe and orderly transfer, which was not adhered to, as evidenced by the lack of communication and involvement of the resident in the discharge process. The resident eventually arrived at the new facility the following day without any new injuries.
Failure to Maintain Required Water Temperatures for Legionella Prevention
Penalty
Summary
The facility failed to adhere to its legionella prevention procedures, as outlined in its policy, which had the potential to affect all residents. The facility's legionella compliance log revealed that the temperatures of water heater tanks #1 and #2 were consistently below the required range from February to July 2024. Specifically, the temperatures were recorded between 110-112 degrees Fahrenheit, whereas the policy required them to be set at 140 degrees Fahrenheit with mixing valves to reduce the temperature upon arrival at residents' rooms. Interviews with the Director of Maintenance, the Administrator, and other staff confirmed that the facility was not following the proper legionella procedures. The legionella binder and policy indicated that hot water boilers should be maintained at or above 140 degrees Fahrenheit to prevent the growth of legionella bacteria. However, observations during the survey confirmed that the water temperatures at the tanks were still below the required levels, at 113 and 112 degrees Fahrenheit, respectively. The facility's water management program, based on CDC and ASHRAE recommendations, emphasized the importance of maintaining water temperatures above 140 degrees Fahrenheit to eradicate legionella bacteria. The program also highlighted that legionella thrives in water temperatures between 77 and 120 degrees Fahrenheit. Despite this, the facility failed to maintain the necessary water temperatures, as confirmed by the review of the water management plan and interviews with staff, including the Director of Nursing and the Regional Nurse.
Failure to Update PASRR Assessments
Penalty
Summary
The facility failed to ensure that Pre Admission Screening and Resident Review (PASRR) assessments were completed accurately and in a timely manner upon a change in condition for four residents. Resident #31's PASRR was not updated to include all mental disorders such as unspecified psychosis, Alzheimer's, dementia, and psychotic disorder, despite these diagnoses being present in the medical record. Similarly, Resident #69's PASRR did not reflect the diagnosis of dementia with mood disturbance, which was confirmed by the Social Services Director (SSD) during an interview. Resident #74's PASRR was not updated to include a current diagnosis of major depressive disorder, and Resident #11's PASRR did not reflect mental health diagnoses such as depression, bipolar disorder, and insomnia, which were added after the initial screening. The facility's policy required the Social Services Director to track each resident's PASRR screening status and refer any resident with a newly evident or possible serious mental disorder to the appropriate state authority for a Level II review. However, this policy was not followed, leading to the deficiencies identified in the report.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in resident rooms, as evidenced by the conditions observed in the rooms of Residents #29 and #55. Resident #29's room had a persistent stench of urine, a sticky bathroom floor, and a non-functional bathroom light. Despite the resident's cognitive intactness and occasional refusal of housekeeping services, the facility did not address these issues promptly. Housekeeping documentation showed multiple refusals of service by the resident, but the broken light was reported several times without repair. Resident #55's room had visible dried blood stains on the linens and floor, which were not addressed for at least a week. The resident was unaware of the blood's origin and expressed a desire for the room to be cleaned. Staff, including a State-tested Nursing Aide, were unaware of the blood until it was pointed out, and the Housekeeping Manager confirmed the oversight. Despite the resident not declining standard cleaning services, the blood remained unaddressed until the surveyor's observation. Additionally, the facility failed to maintain a safe and homelike environment for several residents, as observed in the shared rooms of Residents #5, #17, #20, #22, #30, #41, #65, and #69. These rooms had missing vanity drawers, damaged drywall, and unsecured sinks, which were not repaired despite being evident. The Housekeeping Manager acknowledged these issues and took photographs to report to the Maintenance team. The facility's policy on maintaining a safe and comfortable environment was not adhered to, as evidenced by these deficiencies.
Failure to Complete PASRR for Resident After 30 Days
Penalty
Summary
The facility failed to ensure a Pre Admission Screening and Resident Review (PASRR) was completed for a resident who remained in the facility for over 30 days. The resident, identified as Resident #76, was admitted with diagnoses including chronic obstructive pulmonary disease, pulmonary embolism, diverticulosis, hydrocele, nutritional anemia, and dysuria. Initially, a hospital exemption indicated no diagnosis of mental disorders, but the facility did not complete the required PASRR after the exemption expired and the resident stayed beyond 30 days. Interviews with facility staff, including a Regional Nurse, Social Services Assistant, and Social Services Director, confirmed the oversight. The facility relied on a consulting company to conduct PASRR audits and inform staff of necessary updates, but there was no documentation or evidence of a completed PASRR for Resident #76. The facility's policy required coordination of assessments with preadmission screening and resident review, maintaining a record in the resident's medical record, and completing a state level one screening process for residents staying over 30 days, which was not adhered to in this case.
Failure to Implement Timely Wound Care Treatment
Penalty
Summary
The facility failed to accurately assess and manage a skin impairment for a resident, leading to a deficiency in care. The resident, who had multiple medical diagnoses including quadriplegia and neuromuscular dysfunction, developed a new pressure wound on the left outer thigh. The initial assessment by an LPN noted the wound's measurements and ordered a treatment, but there was no clear documentation on how the wound was acquired. The wound care nurse practitioner was not informed of the wound until four days after its discovery, and the initial treatment orders were not implemented in a timely manner. Throughout the course of treatment, there were multiple instances where the facility did not implement the wound care nurse practitioner's treatment orders within the expected timeframe. For example, a treatment order from early May was not implemented until 11 days later, and another order from mid-June was delayed by 10 days. Additionally, there were discrepancies in the documentation of physician orders, with the facility continuing to use the name and electronic signature of a physician who no longer managed the resident's care. The resident's wound was assessed multiple times, showing changes in size and depth, and at times, the presence of necrotic tissue and biofilm. Despite these assessments, the facility failed to consistently follow the recommended treatment protocols, contributing to the worsening of the wound. Interviews with staff confirmed the delays in implementing treatment orders and the inaccuracies in physician documentation, highlighting a significant lapse in the facility's wound management practices.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to adequately monitor and treat a resident's increased pain level, which was identified as a deficiency during a survey. The resident, who had a complex medical history including surgical aftercare, irritable bowel syndrome, and chronic pain, was not provided with appropriate pain management. Despite having orders for various pain medications, including Oxycodone, Acetaminophen, and Ibuprofen, the facility did not administer these medications consistently according to the resident's reported pain levels. The resident experienced fluctuating pain levels, often reporting moderate to severe pain, yet the facility did not administer the prescribed medications as needed. For instance, Ibuprofen was not given for a pain level of seven on multiple occasions, and Acetaminophen was not administered for lower pain levels. Additionally, the effectiveness of the pain medications was not accurately assessed or documented, leading to inadequate pain management for the resident. The resident's condition deteriorated, resulting in hospitalization due to severe abdominal pain and other complications. Interviews with the resident and the Director of Nursing Services confirmed that the facility did not monitor the resident's pain levels regularly or assess the effectiveness of the pain medications administered. This lack of proper pain management and monitoring contributed to the resident's worsening condition and subsequent hospitalization.
Inappropriate Antibiotic Prescription Due to Lack of UTI Diagnosis
Penalty
Summary
The facility failed to adhere to its antibiotic stewardship program, resulting in the inappropriate ordering of antibiotics for a resident. The resident, who was moderately cognitively impaired and required assistance with toileting, was admitted with several diagnoses, including toxic encephalopathy and hypertensive heart disease. The resident's care plan included monitoring for signs of a urinary tract infection (UTI) due to episodes of incontinence. Despite this, the resident was prescribed Macrobid for a UTI without a confirmed diagnosis. Hospital records indicated no UTI diagnosis, and the resident's symptoms were attributed to hypoglycemia and orthostatic hypotension. The medical record review revealed no evidence supporting the prescription of Macrobid, as there was no increase in incontinence, frequency, or urgency beyond the resident's baseline. The hospital workup showed unremarkable results, and the resident's change in mental status was not linked to a UTI. The Director of Nursing Services confirmed the absence of evidence for the UTI diagnosis during the hospital stay, highlighting a failure in the facility's antibiotic stewardship program to ensure antibiotics were ordered appropriately.
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 850 citations issued within 25 miles in the last 12 months — including the 6 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.
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A prioritized, do-first checklist
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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) |
|---|---|---|---|---|
| Scioto Pointe | 1 mi | ★★★★★ | 21 | 0 |
| Ohio Living Westminster-thurber | 1.3 mi | ★★★★★ | 6 | 0 |
| Capital City Gardens Rehabilitation And Nursing Ce | 1.5 mi | ★★★★★ | 13 | 0 |
| First Community Village Healthcare Ctr | 3.1 mi | ★★★★★ | 0 | 0 |
| Bella Terrace Rehabilitation And Nursing Center | 3.4 mi | ★★★★★ | 4 | 1 |
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 July 2026) and official state health department websites.