Above average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Mcnaughten Pointe Nursing And Rehab during CMS and state inspections, most recent first.
Delayed Notification of Ongoing Nausea and Held Tube Feeding: A resident with a g-tube, dysphagia, chronic respiratory failure, and dialysis dependence had tube feeding held due to nausea, but the physician/NP was not documented as notified when the feeding was first turned off and remained off for more than two hours. The resident continued to report nausea and intermittently refused the feeding to be restarted until later in the day, when the NP and family were finally notified.
A resident with multiple comorbidities, including hemiplegia, neuromuscular bladder dysfunction, chronic diastolic CHF, COPD, and bowel and bladder incontinence, who was fully dependent on staff for toilet hygiene, did not receive proper incontinence care. During observed care, a CNA failed to perform required hand hygiene between glove changes and used a towel that had been partially placed in a plastic bag to dry the resident due to insufficient clean linen, contrary to facility hand hygiene and incontinence care policies.
A resident with quadriplegia, contractures, and a right buttocks pressure ulcer had overlapping wound orders, but the Santyl order was not discontinued when a later triad-based treatment order was received. The TAR documented Santyl as completed on multiple occasions even though the MCS and DON confirmed the current order was for normal saline cleansing, triad paste, and an ABD pad; an LPN also stated she followed the Santyl order after checking PCC and found Santyl in the wound cart.
A resident with multiple medical conditions and a history of falls had repeated falls, but the facility did not complete a thorough RCA after some of the incidents; documentation was limited to assessments and minimal interventions. Another resident with intact cognition left the facility without notifying staff, fell on the street, and was found face down by a bystander, yet the facility did not document a specific RCA or ongoing fall-prevention interventions after the event.
Failure to obtain cultures and sensitivities before antibiotic treatment for recurrent UTI episodes. A resident with diabetes, dysuria, lower abdominal pain, and significant incontinence received multiple broad-spectrum antibiotics for UTI episodes. One UA/culture showed findings suggestive of contamination and no sensitivity testing was done, another ordered UA/culture was not obtained, and the resident later returned from the hospital with an active UTI and was placed on another antibiotic. The DON and MCS confirmed that no culture and sensitivity testing was completed for the antibiotic courses.
A resident with multiple complex medical conditions received a medication for hypotension that required blood pressure monitoring prior to administration. Multiple doses were given without documentation of the required blood pressure readings at the time of administration, and staff interviews confirmed inconsistent documentation practices. The facility did not provide a medication administration policy during the survey.
A resident who was dependent on staff for all ADLs and unable to communicate was left unclothed and exposed in front of an open window while receiving care from two unidentified CNAs. The exposure was confirmed by video footage, observation, and the DON, and concerns about privacy had previously been raised by the resident council and the resident's representative.
A CNA failed to follow enhanced barrier precautions while providing incontinence care to a resident with a feeding tube and tracheostomy, including not wearing a gown, cleansing from back to front, and not removing soiled gloves or performing hand hygiene, as confirmed by video review and the DON.
A resident with multiple medical conditions, including end-stage renal disease, was not provided with the ordered physical therapy sessions three to five times per week. Despite having enough schedule openings, the facility only offered therapy three times per week, and the resident completed fewer sessions due to illness and unavailability. The Therapy Director and DON confirmed the deficiency, noting the resident's dialysis schedule as a potential factor.
Delayed Notification of Ongoing Nausea and Held Tube Feeding
Penalty
Summary
The facility failed to ensure the practitioner was timely notified of ongoing nausea and repeated holding of tube feeding for Resident #118. The resident was admitted with chronic respiratory failure, dependence on respirator status, dependence on renal dialysis, osteomyelitis of the vertebra/sacral/sacrococcygeal region, dysphagia, and gastrostomy status, and was receiving Novasource Renal via g-tube at 40 ml/hr over 22 hours with water flushes at 10 ml/hr over 22 hours. The physician orders allowed the tube feeding to be held on dialysis days, but there were no orders to hold it for nausea or emesis. On 10/15/25, the resident requested that the tube feeding be turned off at 5:55 A.M. because of nausea, and it remained off until 8:07 A.M.; the note states the issue was passed to the next shift and the responsible party was notified, but there was no documentation that the physician or NP were notified. A later note at 10:38 A.M. documented continued nausea with no documentation of physician or NP notification. By 3:48 P.M., the resident continued to request that the tube feeding be turned off at times, and the NP was then notified. At 4:13 P.M., the resident refused to have the tube feeding turned back on after several attempts, and the NP and family were notified. The DON stated the physician or NP should have been notified if a tube feeding was held for more than two hours and verified there was no evidence of notification until the 3:48 P.M. entry.
Failure to Perform Proper Hand Hygiene and Incontinence Care
Penalty
Summary
The deficiency involves failure to provide proper incontinence care and hand hygiene for a resident who was fully dependent on staff for toileting and hygiene. The resident had multiple diagnoses, including hemiplegia and hemiparesis affecting the right dominant side, memory deficit following intracranial hemorrhage, COPD, peripheral vascular disease, neuromuscular bladder dysfunction, chronic diastolic CHF, generalized muscle weakness, and visual loss in one eye. The resident’s MDS showed a BIMS score of 9, dependence on staff for toilet hygiene, impaired upper extremity function on one side, and being always incontinent of both bladder and bowel. During observed incontinence care, a CNA did not perform hand hygiene between glove changes, instead only verbalizing that hand hygiene was being done without actually performing it. The CNA also used a towel that was partially placed inside a plastic bag on the bed to dry the resident’s buttocks after incontinence care because there was not another clean towel available. In an interview, the CNA confirmed not performing hand hygiene and not having enough linen to complete incontinence care with clean linen for all tasks. These actions were inconsistent with the facility’s Hand Hygiene policy, which requires staff to perform hand hygiene when indicated using proper technique, and the Skin: Incontinence Care Protocol, which requires proper hand hygiene and glove use during incontinence care.
Wound Treatment Orders Were Not Followed for a Resident With a Right Buttocks Pressure Ulcer
Penalty
Summary
Physician-ordered wound care for Resident #28’s right buttocks was not accurately followed. The resident was admitted with diagnoses including cervical 5 to cervical 7 incomplete quadriplegia, chronic pain syndrome, congestive heart failure, dysphagia, bilateral hand contractures, depressive disorder, and insomnia. The care plan identified altered skin integrity with a pressure ulcer on the right buttocks and directed staff to provide treatment per physician orders. The resident was non-ambulatory and dependent on staff for activities of daily living, and the quarterly MDS indicated intact cognition. The record showed overlapping wound treatment orders for the right buttocks. One order directed Santyl ointment, while a later order directed cleansing with normal saline, patting dry, applying triad paste, and covering with an ABD pad every shift and as needed. Despite the later order, the TAR documented Santyl treatments as completed on multiple dates in July, August, and September 2025. The MCS confirmed the Santyl order should have been discontinued in July 2025 when the triad order was received, and the DON stated the facility had not received Santyl for the resident since July 2025. An LPN confirmed she completed the Santyl treatment on one date and stated she checked the orders in PCC before doing so, and she found Santyl in the wound treatment cart.
Incomplete fall investigations and inadequate supervision
Penalty
Summary
The facility failed to complete a thorough investigation and root cause analysis for repeated falls involving a resident with significant medical complexity and poor safety awareness. The resident had diagnoses including right heart failure, obstructive sleep apnea, dysphagia, gastrostomy status, prior sudden cardiac arrest, anemia, Down syndrome, restlessness and agitation, constipation, insomnia, hyperlipidemia, and GERD. The care plan identified the resident as a fall risk due to debilitation, weakness, medical conditions, incontinence, Down syndrome, a history of falls, and poor safety awareness, with interventions such as alarms, floor mats, close supervision, and assistance with transfers. The record showed multiple falls over several months, but post-fall documentation for at least one fall consisted only of vital signs and a head-to-toe assessment, and another fall note added only a get-up list intervention without a documented root cause analysis. The DON confirmed that after one fall, the only action taken was to move the resident closer to nurse traffic, with no additional investigation or analysis completed. The facility also failed to ensure adequate supervision and a thorough investigation after another resident fell while outside the facility on an unknown leave of absence. This resident had diagnoses including cerebrovascular disease, brain disorder with bilateral symmetrical gliosis, schizophrenia, and type 2 diabetes mellitus, and was his own responsible party with a BIMS score of 14 indicating intact cognition. The care plan identified fall risk related to incontinence, multiple medical conditions, psychotropic medication use, and bilateral cataracts, with interventions focused on asking for help, keeping the call light within reach, maintaining a clutter-free environment, monitoring medication side effects, and using non-skid socks and proper footwear. On the day of the incident, staff learned from the local ER that the resident had fallen on the street and was in the ER. The roommate reported that the resident put on his hat and said he was going to the store without notifying staff of his leave of absence. EMS later reported that a bystander found the resident face down on the sidewalk, and the resident stated he had left the facility intending to go to the store when he lost his balance and fell forward. The record showed no documented root cause analysis or additional interventions to prevent recurrence after the incident, and the RDON confirmed there was no specific root-cause analysis or ongoing interventions related to the fall.
Failure to obtain cultures and sensitivities before antibiotic treatment for recurrent UTI episodes
Penalty
Summary
The facility failed to obtain cultures and sensitivities before administering antibiotics for multiple urinary tract infection episodes for one resident. The resident had diagnoses including morbid obesity, type 2 diabetes mellitus with diabetic neuropathy, dysuria, and lower abdominal pain, and was assessed as cognitively intact but highly dependent for many activities of daily living, with total dependence for toileting and frequent or total incontinence. Review of the record showed treatment with Levaquin, Nitrofurantoin, and Ciprofloxacin for separate UTI episodes, along with a urine culture order for dysuria and lower abdominal pain and a follow-up urology appointment. For the March episode, the resident’s UA showed abnormalities suggestive of a possible UTI, including turbid clarity, positive leukocyte esterase, elevated WBCs, mildly elevated RBCs, and few bacteria, but the reflex urine culture grew 10,000 to 50,000 colonies/mL of Gram-negative bacilli in three kinds and was interpreted by the lab as suggestive of contamination. No sensitivity testing was performed to identify a specific pathogen to guide antibiotic therapy, and the resident was started on Levaquin. For the July episode, a UA with reflex culture was ordered for dysuria and lower abdominal pain but was not obtained, and the record showed the UA result as autocancelled by the system. The resident was given Pyridium during that period. Later, the resident requested hospital evaluation for bladder incontinence and was found to have an active UTI, after which Ciprofloxacin was ordered upon return. The DON confirmed that no culture and sensitivity was completed for the March episode and stated that the July UA may have been intended to be completed later, but the resident’s symptoms improved after Pyridium and follow-up testing was not completed. The Manager of Clinical Services stated that all antibiotics administered were broad-spectrum and that no culture or sensitivity testing was obtained for any of the broad-spectrum antibiotic courses.
Failure to Document Required Parameters During Medication Administration
Penalty
Summary
The facility failed to ensure that specified parameters were obtained and recorded during medication administration for a resident with complex medical needs. The resident had multiple diagnoses, including tracheostomy, chronic respiratory status, ventilator dependence, dysphagia, hemiplegia, gastrostomy, epilepsy, pleural effusions, vascular dementia, Down Syndrome, end stage renal disease, and depression. The resident was non-communicative and had both short-term and long-term memory problems. Physician orders required that Midodrine, a medication for hypotension, be administered only if the systolic blood pressure was 120 mmHg or less, with instructions to hold the medication if the blood pressure exceeded this threshold. Review of the medication administration record revealed that multiple doses of Midodrine were given without documentation of corresponding blood pressure readings at the time of administration. Interviews with nursing staff and CNAs confirmed that while vital signs are typically obtained and documented, there was no consistent documentation of blood pressure readings specifically tied to the administration of medications with parameters. The Director of Nursing stated that nurses are expected to document vital signs prior to administering such medications, but there was no system trigger to require documentation when the vital sign is within parameters. Additionally, the facility was unable to provide a medication administration policy during the survey.
Resident Exposed During Care Due to Open Window Blind
Penalty
Summary
A resident with acute and chronic respiratory failure, ventilator dependence, dysphagia, and hemiplegia was admitted to the facility and was dependent on staff for all activities of daily living, with documentation indicating the resident was rarely or never understood. Audio/video footage from the resident's room showed two unidentified CNAs providing care while the resident was naked and exposed in front of an open window, with the window blind left open. The room was on the ground floor, making it possible for passersby to see inside. The resident's representative expressed concern about the lack of privacy during care, specifically noting the risk of children next door being able to see into the room. Observation confirmed the blind was open during the day, and the DON reviewed the footage, confirming the exposure. Resident council minutes from a prior meeting also documented requests for CNAs to be reminded to knock before entering rooms to respect privacy, indicating ongoing concerns about resident dignity and privacy.
Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow proper infection control procedures while providing care to a resident who was on enhanced barrier precautions (EBP) due to the presence of a feeding tube and tracheostomy. The CNA was observed via audio/video footage wearing gloves and a mask, but not a gown, as required by EBP protocols. During incontinence care, the CNA cleansed the resident from back to front, which could potentially contaminate the urethra with fecal bacteria. The CNA then repositioned the resident without removing the soiled gloves or performing hand hygiene. The resident involved had significant medical needs, including acute and chronic respiratory failure, ventilator dependence, dysphagia, and hemiplegia, and was dependent on staff for all activities of daily living. The Director of Nursing (DON) confirmed the observed failures in infection control practices and acknowledged the absence of a facility-specific EBP policy, despite following CDC guidelines. The incident was identified during a review of the resident's care and confirmed through interviews and video evidence.
Failure to Provide Ordered Physical Therapy
Penalty
Summary
The facility failed to provide physical therapy as ordered for a resident, leading to a deficiency. Resident #64, who has multiple medical conditions including end-stage renal disease and mild cognitive impairment, was ordered to receive physical therapy three to five times per week. However, during the first week of therapy, she was only offered therapy three times and completed it twice. In the second week, she was again offered therapy three times but completed it only once due to being sick and unavailable on the other days. There was no documentation to support that additional therapy sessions were offered to make up for the missed sessions, resulting in non-compliance with the physician's orders. Interviews with the Therapy Director and the Director of Nursing confirmed the deficiency. The Therapy Director acknowledged that the resident was not offered therapy more than three times per week and that there were enough openings in the schedule to accommodate additional sessions. The Director of Nursing noted that the resident's dialysis schedule, which occurs three times weekly, could affect her availability for therapy. Despite these factors, the facility did not ensure that the resident received the ordered amount of therapy, leading to the deficiency noted in the report.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 967 citations issued within 25 miles in the last 12 months — including the 10 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) |
|---|---|---|---|---|
| Majestic Care Of Whitehall | 1.6 mi | ★★★★★ | 9 | 0 |
| Allbridge Rehabilitation And Nursing Center | 2.1 mi | ★★★★★ | 2 | 0 |
| Mother Angeline Mccrory Manor | 2.1 mi | ★★★★★ | 1 | 0 |
| Eastland Rehabilitation And Nursing Center | 2.8 mi | ★★★★★ | 2 | 0 |
| Robert A Barnes Center | 2.9 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Mcnaughten Pointe Nursing And Rehab.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.